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 Impaired Swallowing
The following are the common risk factors:
- Neuromuscular/perceptual impairment
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 demonstrate feeding methods appropriate to individual situation with aspiration prevented.
- Patient will maintain desired body weight.
Nursing Interventions and Rationale
Here are the nursing assessment and interventions for this stroke nursing care plans.
|Review individual pathology and ability to swallow, noting extent of the paralysis: clarity of speech, tongue involvement, ability to protect airway, episodes of coughing, presence of adventitious breath sounds. Weigh periodically as indicated.||Nutritional interventions and choices of feeding route are determined by these factors.|
|Maintain accurate I&O; record calorie count.||Alternative methods of feeding may be used if swallowing efforts are not sufficient to meet fluid and nutritional needs.|
|Have suction equipment available at bedside, especially during early feeding efforts.||Timely intervention may limit untoward effect of aspiration.|
|Promote effective swallowing: Schedule activities and medications to provide a minimum of 30 min rest before eating.||Promotes optimal muscle function, helps to limit fatigue.|
|Provide pleasant and unhurried environment free of distractions.||Promotes relaxation and allows patient to focus on task of eating.|
|Assist patient with head control, and position based on specific dysfunction.||Counteracts hyperextension, aiding in prevention of aspiration and enhancing ability to swallow. Optimal positioning can facilitate intake and reduce risk of aspiration head back for decreased posterior propulsion of tongue, head turned to weak side for unilateral pharyngeal paralysis, lying down on either side for reduced pharyngeal contraction.|
|Place patient in upright position during and/or after feeding as appropriate.||Uses gravity to facilitate swallowing and reduces risk of aspiration.|
|Provide oral care based on individual need prior to meal.||Patients with dry mouth require moisturizing agents like alcohol-free mouthwashes, before and after eating. Patients with excessive saliva will benefit from use of drying agents before meal and moisturizing agents afterward.|
|Season food with herbs, spices, lemon juice, etc. according to patient’s preference, within dietary restrictions;||Increases salivation, improving bolus formation and swallowing effort.|
|Serve foods at customary temperature and water always chilled.||Lukewarm temperatures are less likely to stimulate salivation so foods and fluids should be served cold or warm as appropriate. Note: Water is the most difficult to swallow.|
|Stimulate lips to close or manually open mouth by light pressure on lips or under the chin if needed.||Aids in sensory retraining and promotes muscular control.|
|Place food of appropriate consistency in unaffected side of mouth.||Provides sensory stimulation (including taste), which may increase salivation and trigger swallowing efforts, enhancing intake. Food consistency is determined by individual deficit. For example: Patients with decreased range of tongue motion require thick liquids initially, progressing to thin liquids, whereas patients with delayed pharyngeal swallow will handle thick liquids and thicker foods better. Note: Pureed food is not recommended because patient may not be able to recognize what is being eaten; and most milk products, peanut butter, syrup, and bananas are avoided because they produce mucus and are sticky.|
|Touch parts of the cheek with tongue blade and apply ice to weak tongue.||Can improve tongue movement and control (necessary for swallowing), and inhibits tongue protrusion.|
|Feed slowly, allowing 30–45 min for meals.||Feeling rushed can increase stress and level of frustration, may increase risk of aspiration, and may result in patient’s terminating meal early.|
|Offer solid foods and liquids at different times.||Prevents patient from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after patient has finished eating foods.|
|Limit or avoid use of drinking straw for liquids;||Although use may strengthen facial and swallowing muscles, if patient lacks tight lip closure to accommodate straw or if liquid is deposited too far back in mouth, risk of aspiration may be increased.|
|Encourage SO to bring favorite foods.||Provides familiar tastes and preferences. Stimulates feeding efforts and may enhance swallowing or intake.|
|Maintain upright position for 45–60 min after eating.||Helps patient manage oral secretions and reduces risk of regurgitation.|
|Encourage participation in exercise program.||May increase release of endorphins in the brain, promoting a sense of general well-being and increasing appetite.|
|Administer IV fluids and/or tube feedings||May be necessary for fluid replacement and nutrition if patient is unable to take anything orally.|
|Coordinate multidisciplinary approach to develop treatment plan that meets individual needs.||Inclusion of dietitian, speech and occupational therapists can increase effectiveness of long-term plan and significantly reduce risk of silent aspiration.|
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