Stroke

Nursing Diagnosis and Care Plan for Stroke-A Student’s Guide

Introduction

A stroke (cerebrovascular accident) is a significant event in an individual’s life. Stroke victims may have to go through costly treatments and rehabilitation, not to mention the emotional toll of the diagnosis. Fortunately, nurses have been able to help those who suffer from this debilitating condition for years, ever since it was first introduced into the medical field. Read on for some information about nursing diagnosis and care plans when it comes to strokes!

As you read, keep in mind that our top writers are ready to help in case you get stuck or cannot complete your nursing assignment due to other reasons such as a busy schedule. All you need to is place an order with us!

Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

What is a Cerebrovascular accident (CVA) or stroke?

A stroke is an event in which blood circulation to the brain, from either a blocked artery or injury to a vein or other structure, results in damage and death of cells. The term cerebrovascular accident (CVA) should not be used often because it implies that there has been some type of accident when this condition cannot occur as the result of an accident.

Stroke implies a sudden impairment of cerebral function caused by a disturbance in the blood supply to that area. The impairment either causes hemorrhage, infarction, or a structural lesion that interrupts the blood supply to an area of brain tissue. For complete recovery from cerebrovascular accident, it is important to take urgent measures like minimizing the damage to an individual’s brain. Although it is difficult to survive a stroke, the few who survive may be left with residual deficits in their physical and mental abilities.

Types of Strokes

There are two main types of strokes:

  • Ischemic
  • Hemorrhagic

Ischemic Stroke

An ischemic stroke occurs when the blood flow to an area of brain tissue is blocked. This type of stroke usually happens because a clot (thrombus) has formed in one of the arteries supplying that part of the brain with oxygen-rich blood. It may be due to atherosclerosis, which causes cholesterol plaques to accumulate on the artery walls and narrows them.

Ischemic stroke is common in older people, who are at an increased risk of developing atherosclerosis. Therefore, preventive treatments that can reduce the risk of atherosclerosis may help lower their chance of having an ischemic stroke.

During an ischemic stroke, the affected area of the brain will not get enough oxygen or glucose, and there is a buildup of lactic acid. Unless these chemicals are removed from the blood, they could build up to levels that cause permanent injury in other body parts apart from ischemic stroke.

Hemorrhagic Stroke

In hemorrhagic strokes, there is bleeding in or around brain tissue. This type of stroke occurs when either a blood vessel wall within the brain ruptures and bleeds (intracerebral hemorrhage), or one outside it leaks into the surrounding tissues causing them to swell with fluids from blood vessels (subarachnoid hemorrhage). Sometimes patients suffer both intracerebral and subarachnoid hemorrhages simultaneously.

This type of stroke usually happens because an artery supplying that part of the brain has been weakened by age-related changes in its lining cells – these are called cerebral amyloid angiopathies.

It has been realized that a traumatic head injury can cause hemorrhagic stroke. There is, therefore, a need for nurses to be able to identify and attend to individuals who suffer from a head injury so that they can immediately receive treatment.

What is the difference between Stroke and TIA?

Although a transient interruption of blood flow to an area of the brain can cause both stroke and Transient Ischemic Attack (TIA), it has been found that they are different in terms of symptoms, prognosis, risk factors, and causes.

A TIA is a temporary interruption of blood flow to the brain. In contrast, a cerebrovascular accident (CVA) is an injury or disturbance in one of the head’s arteries that results in damage and death of cells within part of the brain. A transient event can cause both stroke and TIAs, but they are different when it comes to symptoms, prognosis, risk factors, and causes.

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Signs and Symptoms of Cerebrovascular Accident (CVA) or Stroke

  • The patient will suffer from a sudden loss of sensation, movement, or consciousness. Other signs and symptoms include:
  • Unconsciousness with an inability to awaken a person into a state of alertness;
  • Loss of ability to speak coherently (expressive aphasia);
  • Weakness on one side of the body but not necessarily just on one side.
  • Blurred vision in either eye.
  • Dizziness or vertigo without any cause like anemia, infection, etc.
  • Difficulty recognizing familiar faces or distinguishing between different objects that are close together and also difficulty in understanding what is written while reading.

Expert Tip: A stroke victim should always seek medical attention immediately when this occurs because these may be warning signs for other cerebral events.

Nursing Diagnosis for Stroke

Listed below are the common nursing diagnoses for stroke:

  • Impaired physical mobility
  • Issues with cerebral tissue perfusion
  • Inability to perform self-care due to impaired physical mobility
  • Disturbed sensory perception (e.g., visual, auditory).
  • Impaired verbal communication
  • Coping Challenges
  • Unilateral neglect risk
  • Disuse Syndrome Risk
  • Imbalance (e.g., dizziness)
  • Uncoordinated motor function
  • Sensory overload
  • Inability to focus on a single stimulus
  • Anxiety about death or an incurable condition.
  • Loss of meaning in life.

Impaired physical mobility

This nursing diagnosis is usually given to a cerebrovascular accident (CVA) victim who has suffered an impairment in physical mobility. This can affect the person’s ability to move around, dress themselves, use their hands for self-care activities like feeding and toileting, and perform other daily living tasks (ADLs).

Stroke patients may need assistance with ADLs (e.g., eating, dressing) and may also have an impaired ability to communicate needs and self-care activities, leading to difficulty in coping emotionally and physically.

Issues with cerebral tissue perfusion

The impaired supply of oxygenated blood due to increased intracranial pressure will disrupt neurological functioning by limiting or stopping the proper delivery of nutrients and oxygen needed for cells within that area of brain tissue. The interruption may also cause cell damage or death from the lack of these required substances.

Cerebral tissue perfusion is impaired when there is a decrease in blood flow to the brain or an interruption in its delivery. The stroke victim’s symptoms and complications depend on which brain area has been affected by this lack or interrupted supply.

Inability to perform self-care due to impaired physical mobility

The impairment may affect one side (hemiparesis) or both sides (bilateral paresis) of the body, depending on where it occurs within the brain’s hemispheres. This limits the person’s ability to perform ADLs and other tasks associated with daily life, like dressing themselves and using utensils for feeding themselves mealtime activities.

At this level, the body may also experience muscle spasms or contractions. These are the factors that make this nursing diagnosis so difficult to treat. In most cases, coordination is needed from friends and family to help nurses in handling this scenario.

Disturbed sensory perception

A stroke victim may experience impaired sensation in their extremities, vision impairment, hearing and speech problems, as well as difficulty understanding what is written while reading. Stroke patients may also have a problem with the way they perceive sensations (e.g., touch). This can result from any of the following:

Damage to nerves that carry impulses from skin or muscles which prevents pain signals; Changes in nerve cells such because it’s no longer able to process tactile stimuli; Disturbances between brain regions responsible for language/speech on one side – this includes difficulties comprehending spoken words due to an inability to interpret auditory cues like rapid changes in sound frequency or volume level.

Impaired verbal communication

It is difficult for a stroke victim to speak or understand speech. This makes it hard for them to be rehabilitated with the right care plan and express their needs and what they’re experiencing. It also means they may need assistance communicating with caregivers, friends, and family members who cannot read non-verbal cues such as facial expressions or gesture movements.

The muscles that aid in speech production and articulation may also be affected by this diagnosis. This can lead to difficulties in speaking, maintaining a conversation, understanding or following directions, reading or writing, and other issues associated with the language process, making it difficult for them to express themselves verbally.

Coping Challenges

This is another nursing diagnosis for cerebrovascular accident victims often experience feelings of fear, anxiety, anger, depression due to an altered physical appearance (e.g., paralysis) which can lead a person into feeling like there’s no point at all in trying anymore because nothing will ever change how you feel about yourself from this day forward. Strokes have been linked with changes in mood and behavior, which can be difficult to manage.

This diagnosis also makes it hard for stroke victims to maintain their independence or have an appropriate social life due to the impairments that have been present since the event took place. This may lead them into isolation where they don’t feel like anyone understands what is going on with them anymore – this includes medical professionals who are not used to seeing these types of presentations from patients within their practice area because there are so few cases than most other diagnoses out there.

Unilateral neglect risk

Nurses will need to be mindful of the possibility that a stroke victim may have neglect risk. Neglect is when one side or part of their body does not seem to exist in their mind – this can result from any number of factors such as hemianopia (loss of visual field on one side) and hemineglect syndrome, where they are unable to detect anything on the opposite side because it doesn’t register with them at all.

The ability for nurses to monitor these things is important so that they can intervene before an injury occurs out there while trying activities like bathing themselves or feeding themselves without proper supervision/help being available. Neglect among cerebrovascular accident patients is a major source of injury.

Disuse Syndrome Risk

Cerebrovascular accident leads to a lot of physical changes that are present for stroke victims. These may include loss of muscle function, decreased range of motion, and postural instability, as well as the development in pressure sores due to an inability or difficulty with moving around, which can contribute to long-term disability.

This nursing diagnosis also puts patients at risk for disuse syndrome – where they lose their ability to use limbs because they have been inactive too long without any type of rehabilitation available. This is why they need to be monitored and get care plans put in place so that nurses know how best to help those living with this condition get back on track again through some form or another.

Imbalance (e.g., dizziness)

Nurses will need to be mindful of the imbalances that are associated with this diagnosis. Strokes often affect one side or part of their body, which can lead to problems with balance, specifically dizziness and vertigo – where they feel like they’re spinning while, in reality, they may not be moving at all. This could cause them to lose consciousness or trip over something on accident because it’s so difficult for them to maintain an appropriate equilibrium level when dealing with these issues.

The ability for nurses is important here as well since there needs to be intervention before injuries occur out there while trying activities like bathing themselves or feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball).

Uncoordinated motor function

Strokes have been known to affect a person’s coordination. This is because of the damage that has been done from being deprived of oxygen due to a lack thereof reaching their brain, which can lead them on an irreversible course if not enough rehabilitation services are available for those who need it.

Motor functioning is a major problem with this diagnosis – because it can lead to an inability or difficulty in performing certain types of movements.

The ability for nurses is again important here since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves, feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball).

Eating Challenges

Nurses will need to be mindful of any eating or drinking problems that are associated with this diagnosis – namely dysphagia, where they experience difficulty swallowing food or liquids as well as esophageal reflux and aspiration pneumonia risk, which is when there are excessive amounts of fluid in their airway while trying breathing through both nostrils and mouth-to-mouth respiration.

If a patient is suffering from this, they need to be monitored because if it becomes severe enough, the person could risk developing aspiration pneumonia which can lead to death due to infection in their lungs – and might not even know that anything was wrong with them until it’s too late since sometimes people don’t realize when things are happening orally (like breathing) versus an injury on another part of their body: there needs to be intervention before injuries occur out there while trying activities like bathing themselves or feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball).

Loss of sensation

The loss of sensation associated with this diagnosis may also affect how nurses interact with patients suffering from it. They may need to be mindful of the patient’s level of sensitivity and adjust their touch accordingly for them not to become too overwhelmed by stimuli, which could cause things to get worse rather than better over time.

The ability for nurses is important here as well since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves or feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball).

Inability to focus on a single stimulus.

A lack of concentration may also be a problem for those who have this diagnosis. This is because it can lead to an inability or difficulty in performing certain types of movements, which could be dangerous if they are out there driving and need to make quick decisions and perform maneuvers like braking quickly/steering suddenly (possibly without realizing the appropriate time-frame).

The ability for nurses is again important here since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves, feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball), etc.

Sensory overload

The sensory overload associated with this diagnosis may also affect how nurses interact with patients suffering from it. They will need to be mindful of the patient’s level of sensitivity and adjust their touch accordingly for them not to become too overwhelmed by stimuli, which could cause things to get worse rather than better over time.

The ability for nurses is important here as well since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves or feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball).

Blocked circulation

Getting enough blood flow throughout an individual’s body can also pose problems for those who have this diagnosis. This is because it can lead to an inability or difficulty in performing certain types of movements, which could be dangerous if they are out there driving and need to make quick decisions and perform maneuvers like braking quickly/steering suddenly (possibly without realizing the appropriate time-frame).

The ability for nurses is again important here since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves, feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball), etc.

Anxiety about death or an incurable condition

Anxiety about death or an incurable condition may also affect how nurses interact with patients suffering from it. They will need to be mindful of the patient’s level of sensitivity and adjust their touch accordingly for them not to become too overwhelmed by stimuli, which could cause things to get worse rather than better over time.

The ability for nurses is important here as well since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves or feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball).

Memory lapses

A side-effect associated with this diagnosis can include memory problems – such as forgetting events, conversations, tasks. This may make it difficult for patients to remember when they need medication or take other steps associated with their care plan (such as drinking fluids).

The ability for nurses is important here since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves, feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball), etc.

Drowsiness

Getting enough sleep can also pose problems for those who have this diagnosis – which could lead them to not getting the appropriate amount of rest needed each night to keep up with daily demands and responsibilities that are so much more demanding than what someone might be used to.

The ability for nurses is important here since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves or feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball).

loss of meaning in life

For those who have this nursing diagnosis, it might be difficult for them to find meaning in life, leading to a sense of depression or hopelessness. (i.e., “why bother working hard?”)

The ability for nurses is important here since they will need to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves or feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball).

Nursing Care Plans for Stroke Patients

The list below illustrates common nursing care plans for stroke:

  • Effective neurologic assessment and monitoring
  • Managing GI problems
  • Monitoring for changes in mental status and level of consciousness
  • Assisting with maintaining a patent airway
  • Preventing or reducing risk for aspiration pneumonia
  • Maintaining safety from falls
  • Monitoring for and preventing dehydration
  • Providing emotional support to the patient and family
  • Promptly reporting critical status changes
  • Education about stroke recovery

Effective neurologic assessment and monitoring

Effective neurologic assessment and monitoring is important in minimizing the risk of secondary injuries to the brain and spinal cord. Nurses must assess how well a patient can move their limbs, swallow, communicate verbally or nonverbally with others (i.e., crying), as well as whether any other medical problems might exist that need to be addressed before they worsen.

This nursing care plan involves assessing a stroke patient’s cognitive functioning and mental status to determine their level of consciousness. The nurses also make sure the patient is safe from falls by being positioned on their side so that fluids will not collect in the lungs or be unable to use assistive devices like walkers if needed.

These nurses need to observe changes in mental status and level of consciousness since stroke patients can experience memory problems such as forgetting events, conversations, tasks. This may make it difficult for patients to remember when they need medication or which steps are associated with their care plan (such as drinking fluids).

Managing GI problems

Stroke patients may experience problems with their GI system, such as constipation, diarrhea, and nausea. Nurses need to monitor these symptoms to prevent dehydration from occurring.

It is also necessary for the nurse to assist stroke victims with maintaining a patent airway while sleeping so that it will be easier when waking up and they will not struggle to breathe.

If these GI problems are left untreated, they can lead to aspiration pneumonia. Stroke patients are at a higher risk of developing this than those who have not been diagnosed with the condition due to their inability to swallow properly or move food around in their mouth and difficulty speaking.

Preventing or reducing risk for aspiration pneumonia

Nurses need to prevent or reduce the risks of aspirating, such as by feeding stroke patients in a sitting position and using cups instead of straws when drinking fluids, so that food particles from their mouths do not go into their lungs. It is important for these nurses to monitor for and prevent dehydration.

Maintaining safety from falls.

Nurses will need to take care of the patients’ safety from falls by assigning a family member or friend. Due to their condition, stroke patients may also rely on assistive devices such as walkers or canes.

Nurses should be available to facilitate the patient’s movement from one place to another, such as using a wheelchair or rolling armchair. This is a nursing diagnosis aimed at making the patient comfortable.

Monitoring for and preventing dehydration

Nurses need to monitor a patient’s level of consciousness, cognitive functioning, mental status to know when changes have occurred so that they can report them promptly. Stroke patients may experience depression or hopelessness due to their condition, leading to neglecting their basic needs such as drinking fluids. It is important for nurses to monitor a patient’s level of consciousness and provide emotional support, especially when communicating with the family members or friends present, to keep everyone informed and feel valued during this difficult time.

If stroke patients are left dehydrated for long, they are prone to having problems with the GI system, such as constipation, diarrhea, nausea. Nurses need to monitor these symptoms in order to prevent dehydration from occurring and report any changes promptly.

If stroke patients suffer from chronic conditions or have been hospitalized before they had a stroke, then it may be necessary for them to undergo rehabilitation therapy after the acute phase has ended. Stroke patients may be at a higher risk for depression or hopelessness due to their condition, which can lead to neglecting their basic needs such as drinking fluids, so it is important that nurses monitor them and provide emotional support.

Monitoring for changes in mental status and level of consciousness

Nurses need to be aware if the stroke patient’s condition worsens so that they can take appropriate action, such as calling a doctor or emergency services when necessary. Nurses should monitor the mental status of these patients to ensure they are not experiencing depression, and if they do, it can be addressed for them to get the care that is needed. This demonstrates the importance of mental status stroke nursing care.

The mental status of a person is assessed by observing them and asking questions about how they are feeling. In this way, the nurse will be able to assess whether the person is experiencing depression or not. From here, the nurse will be informed of the next steps to take towards the patient’s recovery.

Promptly reporting critical status changes.

This stroke nursing care plan involves nurses being prompt in their reports when the patient’s status changes from critical to stable so that they can meet many of the needs of stroke victims. On the other hand, when the patient’s situation changes from stable to critical, the nurses should also be prompt in notifying medical professionals to take appropriate action.

Critical changes like breathing difficulties, decreasing blood pressure, or heart rate, decreased cognitive functioning should be monitored and reported as soon as possible. Moreover, impaired physical mobility-related issues should be keenly checked.

Assisting with maintaining a patent airway

This care plan also involves nurses assisting the patient with maintaining a patent airway when they are sleeping. These nurses need to be aware of any signs or symptoms that might indicate an obstruction in the respiratory tract so that it can be addressed quickly before it worsens and becomes life-threatening.

A patent airway for a stroke patient means that they are able to take in a full, deep breath and exhale. This is different from someone who might have difficulty breathing because of asthma or other reasons like smoking.

Education about stroke recovery

Nurses should also be aware of the patient’s level of mobility post-stroke and what type of rehabilitation will need to be done. They should also be familiar with the different types of equipment that might help the patient recover.

Family members should be aware of the relevant information so that they can be supportive and know what to do when the patient returns home. This will save the patient from having to repeat the same mistakes over and over again. When people get fully educated on matters of stroke, they can get better care.

Expected Outcomes

The expected outcomes of nursing care plans for stroke patients include:

  • Patients are at a lower risk for depression or despair
  • Stroke patients have an increased rate of recovery and decrease in symptoms due to early identification, management, and support
  • Family members know how to be supportive and provide emotional care when the patient returns home.
  • An improved level of consciousness for the patient.
  • The patient has a higher quality of life post-stroke because they are able to manage symptoms more effectively with early interventions, support, and education on stroke recovery.
  • There is no sign of further deterioration in the patient’s condition.
  • There is no sign of suspicion for a new stroke or any other complication that could arise as a result of an existing stroke.
  • Education about managing symptoms post-stroke will help patients live with less frustration and fewer expectations they can’t meet, which should lead them to more fulfilling lives.
  • The patient’s cognitive functioning is stable.

How to Prevent Stroke

  • Stroke can be prevented in different ways like:
  • Not leading a sedentary lifestyle
  • Eating a healthy diet with fruits and vegetables
  • Avoiding smoking or taking recreational drugs like cocaine.
  • Stroke is also prevented by maintaining normal blood pressure and cholesterol levels, avoiding high-risk activities, not drinking too much alcohol, eating foods that lower the risk of stroke (such as whole grains and vegetables), exercising, maintaining a healthy weight, not sleeping too much or too little.
  • Avoid stress as it can lead to stroke.
  • Nurses should use caution when administering medications that are known to increase the risk of vascular events because they could cause an adverse event in this population (blood pressure medication like beta-blockers).

Key Takeaways

Stress is a dangerous condition in contemporary society. It is a major risk factor for stroke.

Nurses are trained to identify and address the presence of stress in their patients -they should also be educated on how to help people manage this condition so that they can live with less frustration, fewer expectations they will not meet, and more fulfilling lives. Violence against women, rape, sexual abuse, or trauma can all be sources of stress in someone’s life.

Nursing intervention for stroke patients is focused on preventing further deterioration and providing emotional care to those who have already suffered a stroke

Strokes are preventable through lifestyle changes like not smoking or taking recreational drugs, maintaining normal blood pressure levels, avoiding high-risk activities such as drinking too much alcohol or eating too many high-cholesterol foods.

Strokes are also prevented by maintaining a healthy weight, not sleeping too little, or exercising regularly.

Nurses should be aware of the different types of equipment that might need to be used with patients who have suffered strokes to recover and what level of mobility they will still be able to have.

Nurses should also be aware of the different levels and types of care that can be used for a stroke patient, from full-time nursing home care today programs or rehabilitation centers where they might go on as many days per week as are necessary.

Finally, stroke patients may need assistance with bathing, dressing, feeding, toileting, and moving.

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