Included in this guide are 12 nursing diagnoses for stroke (cerebrovascular accident) nursing care plans. Know about the nursing interventions for stroke, assessment, goals, and related factors of each nursing diagnosis and care plan.
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 a pathological condition of the cerebral vessels of the entire cerebrovascular system. It is the sudden impairment of cerebral circulation in one or more blood vessels supplying the brain. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by 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 a full 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 of stroke, with thrombosis being the leading 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 primary nursing care plan goals for patients with stroke depend on the phase of CVA the client is in. During the acute phase of CVA, efforts should focus on survival needs and prevent further complications. Care revolves around efficient continuing neurologic assessment, support of respiration, continuous monitoring of vital signs, careful positioning to avoid aspiration and contractures, management of GI problems, and monitoring of electrolyte and nutritional status. Nursing care should also include measures to prevent complications.
Listed below are 12 nursing diagnoses for stroke (cerebrovascular accident) nursing care plans:
- Risk for Ineffective Cerebral Tissue Perfusion
- Impaired Physical Mobility
- Impaired Verbal Communication
- Acute Pain
- 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
NOTE: This nursing care plan is recently updated with new content and a change in formatting. Nursing assessment and nursing interventions are listed in bold and followed by their specific rationale in the following line. Still, when writing nursing care plans, follow the format here.
Risk for Impaired Swallowing
Stroke can often cause dysphagia due to impaired function of the mouth, tongue, and larynx.
Risk factors may include
The following are the common risk factors:
- Neuromuscular/perceptual impairment
Desired goals and outcomes
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 Assessment and Rationales
These are the nursing assessment for this stroke nursing care plan.
1. Review individual pathology and ability to swallow, noting the extent of the paralysis: clarity of speech, tongue involvement, ability to protect the airway, episodes of coughing, presence of adventitious breath sounds. Weigh periodically as indicated.
Assess the patient’s ability to swallow as soon as possible and before any oral intake. Nutritional interventions and choices of feeding routes are determined by these factors.
2. Maintain accurate I&O; record calorie count.
Alternative feeding methods may be used if swallowing efforts are not sufficient to meet fluid and nutritional needs.
Nursing Interventions and Rationales
Here are the nursing interventions for this stroke nursing care plan.
1. Have suction equipment available at the bedside, especially during early feeding efforts.
Timely intervention may limit the untoward effects of aspiration.
2. 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.
3. Provide a pleasant and unhurried environment free of distractions.
Promotes relaxation and allows the patient to focus on the task of eating.
4. Assist patient with head control and position based on specific dysfunction.
Counteracts hyperextension, aiding in the prevention of aspiration and enhancing the ability to swallow. Optimal positioning can facilitate intake and reduce the 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.
5. Place the patient in an upright position during and after feeding as appropriate.
To reduce the risk of aspiration by use of gravity to facilitate swallowing. Have the patient sit upright and tuck the chin towards the chest as they swallow.
6. Provide oral care based on individual needs before a meal.
Patients with dry mouth require moisturizing agents like alcohol-free mouthwashes before and after eating. Patients with excessive saliva will benefit from the use of drying agents before meals and moisturizing agents afterward.
7. Season food with herbs, spices, lemon juice, etc., according to the patient’s preference, within dietary restrictions.
Increases salivation, improving bolus formation and swallowing effort.
8. Serve foods at normal temperature, and water is always chilled.
Lukewarm temperatures are less likely to stimulate salivation, so foods and fluids should be served cold or warm as appropriate. Water is the most difficult to swallow.
9. 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.
10. Place food of appropriate consistency on the unaffected side of the mouth.
Provides sensory stimulation (including taste), increasing salivation and triggering swallowing efforts, enhancing intake. Food consistency is determined by the 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 patients may not recognize what is being eaten, and most milk products, peanut butter, syrup, and bananas are avoided because they produce mucus and are sticky.
11. Touch parts of the cheek with a tongue blade and apply ice to the weak tongue.
It can improve tongue movement and control (necessary for swallowing) and inhibits tongue protrusion.
12. Feed slowly, allowing 30–45 min for meals.
Feeling rushed can increase stress and frustration, may increase the risk of aspiration, and may result in the patient’s terminating meal early.
13. Offer solid foods and liquids at different times.
It prevents the patient from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after the patient has finished eating foods.
14. Limit or avoid the use of drinking straw for liquids.
Although use may strengthen facial and swallowing muscles, if the patient lacks tight lip closure to accommodate straw or if the liquid is deposited too far back in the mouth, the aspiration risk may increase.
15. Encourage SO to bring favorite foods.
Provides familiar tastes and preferences. Stimulates feeding efforts and may enhance swallowing or intake.
16. Maintain the upright position for 45–60 min after eating.
Helps patient manage oral secretions and reduces the risk of regurgitation.
17. Encourage participation in an exercise program.
May increase release of endorphins in the brain, promoting a sense of general well-being and increasing appetite.
19. Coordinate a multidisciplinary approach to develop a treatment plan that meets individual needs.
The inclusion of dietitians, speech and occupational therapists can increase the effectiveness of the long-term plans and significantly reduce the risk of silent aspiration.
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to neurological disorders:
- Alzheimer’s Disease | 15 Care Plans
- Brain Tumor | 3 Care Plans
- Cerebral Palsy | 7 Care Plans
- Cerebrovascular Accident | 12 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
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:
- Acharya, A. B., & Wroten, M. (2017). Wernicke Aphasia.
- Amarenco, P., Lavallée, P. C., Monteiro Tavares, L., Labreuche, J., Albers, G. W., Abboud, H., … & Wong, L. K. (2018). Five-year risk of stroke after TIA or minor ischemic stroke. New England Journal of Medicine, 378(23), 2182-2190.
- Crawford, A., & Harris, H. (2016). Caring for adults with impaired physical mobility. Nursing2020, 46(12), 36-41.
- Cumbler, E., & Glasheen, J. (2007). Management of blood pressure after acute ischemic stroke: An evidence‐based guide for the hospitalist. Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine, 2(4), 261-267.
- Dowswell, G., Dowswell, T., & Young, J. (2000). Adjusting stroke patients’ poor position: an observational study. Journal of Advanced Nursing, 32(2), 286-291.
- Gorelick, P. B., Farooq, M. U., & Min, J. (2015). Population-based approaches for reducing stroke risk. Expert review of cardiovascular therapy, 13(1), 49-56.
- Hansen, A. P., Marcussen, N. S., Klit, H., Andersen, G., Finnerup, N. B., & Jensen, T. S. (2012). Pain following stroke: a prospective study. European journal of pain, 16(8), 1128-1136.
- Kazemzadeh, Z., Manzari, Z. S., & Pouresmail, Z. (2017). Nursing interventions for smoking cessation in hospitalized patients: a systematic review. International nursing review, 64(2), 263-275.
- Kumar, R., Metter, E. J., Mehta, A. J., & Chew, T. (1990). Shoulder pain in hemiplegia. The role of exercise. American journal of physical medicine & rehabilitation, 69(4), 205-208.
- Lankhorst, G. J., & Bouter, L. M. (2002). Risk factors for hemiplegic shoulder pain: A systematic review. Critical Reviews’ in Physical and Rehabilitation. Medicine, 14(3&4), 223-233.
- Li, J., Yuan, M., Liu, Y., Zhao, Y., Wang, J., & Guo, W. (2017). Incidence of constipation in stroke patients: a systematic review and meta-analysis. Medicine, 96(25).
- Li, Z., & Alexander, S. A. (2015). Current evidence in the management of poststroke hemiplegic shoulder pain: a review. Journal Of Neuroscience Nursing, 47(1), 10-19.
- Marler, J. R., Tilley, B. C., Lu, M., Brott, T. G., Lyden, P. C., Grotta, J. C., … & NINDS rt-PA Stroke Study Group. (2000). Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology, 55(11), 1649-1655.
- Menon, B. K., & Demchuk, A. M. (2011). Computed tomography angiography in the assessment of patients with stroke/TIA. The Neurohospitalist, 1(4), 187-199.
- Ovbiagele, B., Kidwell, C. S., Starkman, S., & Saver, J. L. (2003). Neuroprotective agents for the treatment of acute ischemic stroke. Current neurology and neuroscience reports, 3(1), 9-20.
- Purnawinadi, I. G. (2019). The Characteristics Of Impaired Physical Mobility Among Patients With Stroke. Klabat Journal of Nursing, 1(1), 1-8.
- Sacco, R. L. (2004). Risk factors for TIA and TIA as a risk factor for stroke. Neurology, 62(8 suppl 6), S7-S11.
- Shah, R. S., & Cole, J. W. (2010). Smoking and stroke: the more you smoke the more you stroke. Expert review of cardiovascular
- Tyson, S. F., & Chissim, C. (2002). The immediate effect of handling technique on range of movement in the hemiplegic shoulder. Clinical rehabilitation, 16(2), 137-140.
- Xie, H. M., Guo, T. T., Sun, X., Ge, H. X., Chen, X. D., Zhao, K. J., & Zhang, L. N. (2021). Effectiveness of Botulinum Toxin A in Treatment of Hemiplegic Shoulder Pain: A Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehabilitation.