"NURSING CARE IN CLIENTS WITH CEREBROVASCULAR

ACCIDENT (CVA)"
PAPERS
Proposed to meet one of the tasks in English language courses II

Level I Semester II
Nursing Science Non-Regular
1.
2.

Compiled By Group 5
NPM. 213215
NPM. 213215

3.

NPM. 213215

4.

NPM. 213215

5.

NPM. 213215

6.

NPM. 213215

INSTITUTE OF HEALTH SCIENCE

JENDERAL ACHMAD YANI CIMAHI
2016-2017

FOREWORD

Assalamualaikum Wr. Wb.

All praise and gratitude to Allah SWT said over who has provided an
abundance of His grace and guidance, not to forget peace and blessings authors
convey to the Prophet Muhammad, so we can complete the paper properly. The
paper is titled "Nursing In Clients with Stroke". This paper made to meet the
requirements in completing the task groups of subjects of English II.
This paper can be resolved for the help and support from various
parties, therefore, on this occasion the author would like to thank all those who
have participated in the making of this paper.
May the good deeds which can be given a reply in the world and be
rewarded in the hereafter. Not forgetting also the authors apologize for any
shortcomings in the manufacture of this paper. The author recognizes the paper
is still much to be improved, to the authors expect criticism and suggestions that
can build to perfection this paper.
Wassalamu'alaikum Wr. Wb.
Author

TABLE OF CONTENTS

FOREWORD............................................................................................ ii
TABLE OF CONTENTS............................................................................. iii
CHAPTER I INTRODUCTION.....................................................................1
A. Background...................................................................................... 1
B. Purpose........................................................................................... 2
C. Benefits of Writing............................................................................. 3
D. Methodology Writing..........................................................................3
CHAPTER II LITERATURE STROKE...........................................................4
A. Definitions........................................................................................ 4
B. Classification.................................................................................... 4
C. Causes of Stroke...............................................................................4
D. Risk Factors for Stroke.......................................................................5
E. Clinical Manifestations.......................................................................7
F. Diagnostic Studies.............................................................................8
G. Prevention...................................................................................... 11
H. Medical Management.......................................................................12
I. Management of Complications..........................................................12
CHAPTER III NURSING CARE.................................................................13
A. Nursing Assessment........................................................................13
1. Acute Phase............................................................................... 13
2. Postacute Phase.........................................................................13
B. Nursing Diagnoses..........................................................................14
C. Nursing Priorities............................................................................. 14
D. Nursing Interventions.......................................................................14
E. Evaluation...................................................................................... 33
F. Discharge Goals.............................................................................34
REFERENCES....................................................................................... 35

CHAPTER I
INTRODUCTION
A. Background
Stroke is the 3rd leading cause of death in America (#1 in Portugal
and in Asia) and the primary cause of adult disability. Stroke accounts for 1 of
every 18 deaths in the US. About 795,000 Americans suffer a new or
recurrent stroke each year. In 2008, the estimated stroke-related medical
costs were ~$65.5 billion.
A stroke or brain attack occurs when a blood clot blocks the blood
flow in a vessel or artery or when a blood vessel breaks. There are two types
of brain attacks - ischemic and hemorrhagic. When brain cells die during a
stroke, abilities controlled by that area of the brain are lost. These abilities
include speech, movement and memory. How a stroke patient is affected
depends on where the stroke occurs in the brain and how much the brain is
damaged.
With ischemic strokes, a blood clot blocks or plugs a blood vessel in
the brain. Limited treatments are tPA clot buster or surgical removal of the
clot within a 2-3 hours time-window (and sometimes up to 6 hours). An
estimated 7,000,000 Americans 20 years of age have had a stroke. Overall
stroke prevalence during this period is an estimated 3.0%.
The prevalence of silent cerebral infarction between 55 and 64 years of

age is ~11%. This prevalence increases to 22% between 65 and 69

years of age, 28% between 70 and 74 years of age, 32% between 75
and 79 years of age, 40% between 80 and 85 years of age, and 43% at
85 years of age. Application of these rates to 1998 US population
estimates results in an estimated 13 million people with prevalent silent
stroke every year.
Silent stroke may be important in the development of AD since cerebral

perfusion is often found to be reduced in association with an increased

oxygen extraction fraction during an attack, a hemodynamic presentation
typically found in AD patients.

 For the incidence, it is estimated that each year, ~795 000 people

experience a new or recurrent stroke. From 1999 data, approximately

610,000 of these are first attacks, and 185 000 are recurrent attacks).
On average, every 40 seconds, someone in the US has a stroke. On

average, every 4 minutes, someone dies of a stroke. Stroke accounted

for ~1 of every 18 deaths in the United States in 2007.
Each year, ~55,000 more women than men have a stroke
It now appears that coronary artery bypass grafting (CABG) surgery may

induce cognitive loss in as many as 50% of patients undergoing this

procedure.
The number of TIAs in the United States has been estimated to be

~200,000 to 500,000 per year, with a population prevalence into ~5

million people. The prevalence of TIA increases significantly with older
age. Approximately half of all patients who experience a TIA fail to report
it to their healthcare providers.
With hemorrhagic strokes, a blood vessel in the brain breaks or ruptures.
The occurrence rate of ischemic stroke is ~83% and for hemorrhagic it is ~17%.
Among people 45 to 64 years of age, approximately 8% to 12% of

ischemic strokes and 37% to 38% of hemorrhagic strokes result in death

within 30 days.
In a study of people 65 years of age recruited from a random sample of

Health Care Financing Administration Medicare Part B eligibility lists in

four US communities, the 1-month case fatality rate was 12.6% for all
strokes, 8.1% for ischemic strokes, and 44.6% for hemorrhagic strokes.
Approximately half of incident childhood strokes are hemorrhagic. Despite

current treatment, 1 of 10 children with ischemic or hemorrhagic stroke

will have a recurrence within 5 years.
B. Purpose
1. General Purpose
Explaining overall about nursing care in clients with cerebrovascular
accident (CVA)
2. Special Purpose
a. Knowing the description about definition of CVA
b. Knowing the description about classification
c. Knowing the description about cause of stroke

d.
e.
f.
g.
h.

Knowing the description about clinical manifestation

Knowing the description about diagnostic studies
Knowing the description how about prevention of stroke
Knowing the description about medical management of stroke
Knowing the description about management of complications stroke

C. Benefits of Writing
A work can be said to be good if it can provide benefits that can be
used to improve aspects of life towards a better one in the field of health . As
for the expected benefits authors, there are:
1. For Student
To increase

knowledge

about

nursing

care

in

clients

with

cerebrovascular accident (CVA).

2. For the general reader
To increase the knowledge of the nursing profession . Adding insight
and knowledge of the author. Add critical of the author .
D. Methodology Writing
Writing method used to compile this paper is Study Library or
methods Literature , studying the reference books that informed theoretical
and relavan . And then, sought information from the Internet or use through
Information and Communication Technology .

E.

CHAPTER II
LITERATURE STROKE
A. Definitions
A stroke (apoplexy) is the sudden onset of weakness, numbness,
paralysis, slurred speech, aphasia, problems with vision and other
manifestations of a sudden interruption of blood flow to a particular area of
the brain. The ischemic area involved determines the type of focal deficit that
is seen in the patient.
Stroke occurs when the supply of blood to the brain is either
interrupted or reduced. When this happens, the brain does not get enough
oxygen or nutrients which cause brain cells to die. There are three main
kinds of stroke; ischemic and hemorrhagic.

B. Classification
There are two types of stroke :
1.Ischemic stroke is similar to a heart attack, except it occurs in the blood
vessels of the brain. Clots can form in the brain's blood vessels, in blood
vessels leading to the brain, or even in blood vessels elsewhere in the
body and then travel to the brain. These clots block blood flow to the
brain's cells. Ischemic stroke can also occur when too much plaque (fatty
deposits and cholesterol) clogs the brain's blood vessels. About 80% of all
strokes are ischemic.
2.Hemorrhagic (heh-more-raj-ik) strokes occur when a blood vessel in the
brain breaks or ruptures. The result is blood seeping into the brain tissue,
causing damage to brain cells. The most common causes of hemorrhagic
stroke are high blood pressure and brain aneurysms. An aneurysm is a
weakness or thinness in the blood vessel wall.

C. Causes of Stroke
The primary pathophysiology of stoke is an underlying heart or blood
vessel disease. The secondary manifestations in the brain are the result of
one or more of these underlying diseases or risk factors. The primary
pathologies include hypertension, atherosclerosis leading to coronary artery
disease, dyslipidemia, heart disease, and hyperlipidemia. The two types of
stroke that result from these disease states are ischemic and hemorrhagic
strokes.

D. Risk Factors for Stroke

A risk factor is a condition or behavior that increases your chances of
getting a disease. Having a risk factor for stroke doesn't mean you'll have a
stroke. On the other hand, not having a risk factor doesn't mean you'll avoid
a stroke. But your risk of stroke grows as the number and severity of risk
factors increase.
These risk factors for stroke cannot be changed by medical treatment
or lifestyle changes.
1.Age. Although stroke risk increases with age, stroke can occur at any age.
Recent studies have found that stroke rates among people under 55 grew
from 13 percent in 1993-1994, to 19 percent in 2005. Experts speculate
the increase may be due to a rise in risk factors such as diabetes, obesity,
and high cholesterol.
2.Gender. Men have a higher risk for stroke, but more women die from
stroke.
3.Race. People from certain ethnic groups have a higher risk of stroke. For
African Americans, stroke is more common and more deadly even in
young and middle-aged adults than for any ethnic or other racial group
in the U.S. Studies show that the age-adjusted incidence of stroke is
about twice as high in African Americans and Hispanic Americans as in

Caucasians. An important risk factor for African Americans is sickle cell

disease, which can cause a narrowing of arteries and disrupt blood flow.
4.Family history of stroke. Stroke seems to run in some families. Several
factors may contribute to familial stroke. Members of a family might have
a genetic tendency for stroke risk factors, such as an inherited
predisposition for high blood pressure (hypertension) or diabetes. The
influence of a common lifestyle among family members could also
contribute to familial stroke.

Some of the most important risk factors for stroke that CAN be treated are:
1. High Blood Pressure
High blood pressure, also called hypertension, is by far the most
potent risk factor for stroke. If your blood pressure is high, you and your
doctor need to work out an individual strategy to bring it down to the
normal range. Here are some ways to reduce blood pressure:

Maintain proper weight.

Avoid drugs known to raise blood pressure.

Cut down on salt.

Eat fruits and vegetables to increase potassium in your diet.

Exercise more.
Your doctor may prescribe medicines that help lower blood pressure.

Controlling blood pressure will also help you avoid heart disease,
diabetes, and kidney failure.

2. Smoking
Cigarette smoking has been linked to the buildup of fatty substances
in the carotid artery, the main neck artery supplying blood to the brain.
Blockage of this artery is the leading cause of stroke in Americans. Also,
nicotine raises blood pressure, carbon monoxide reduces the amount of
oxygen your blood can carry to the brain, and cigarette smoke makes your
blood thicker and more likely to clot.
Your doctor can recommend programs and medications that may help
you quit smoking. By quitting -- at any age -- you also reduce your risk of
lung disease, heart disease, and a number of cancers including lung
cancer.
3. Heart Disease
Heart disease, including common heart disorders such as coronary
artery disease, valve defects, irregular heart beat, and enlargement of one
of the heart's chambers, can result in blood clots that may break loose
and block vessels in or leading to the brain. The most common blood
vessel disease, caused by the buildup of fatty deposits in the arteries, is
called atherosclerosis, also known as hardening of the arteries.
Your doctor will treat your heart disease and may also prescribe
medication, such as aspirin, to help prevent the formation of clots. Your
doctor may recommend surgery to clean out a clogged neck artery if you
match a particular risk profile.
4. High Blood Cholesterol
A high level of total cholesterol in the blood is a major risk factor for
heart disease, which raises your risk of stroke. Your doctor may
recommend changes in your diet or medicines to lower your cholesterol.
5. Warning Signs or History of a Stroke

Experiencing warning signs and having a history of stroke are also

risk factors for stroke. Transient ischemic attacks, or TIAs, are brief
episodes of stroke warning signs that may last only a few moments and
then go away. If you experience a TIA, get help at once.
If you have had a stroke in the past, it's important to reduce your risk
of a second stroke. Your brain helps you recover from a stroke by drawing
on body systems that now do double duty. That means a second stroke
can be twice as bad.
6. Diabetes.
Having diabetes is another risk factor for stroke. You may think this
disorder affects only the body's ability to use sugar, or glucose. But it also
causes destructive changes in the blood vessels throughout the body,
including the brain.
Also, if blood glucose levels are high at the time of a stroke, then
brain damage is usually more severe and extensive than when blood
glucose is well-controlled. Treating diabetes can delay the onset of
complications that increase the risk of stroke.

E. Clinical Manifestations
General signs and symptoms include numbness or weakness of face,
arm, or leg (especially on one side of body); confusion or change in mental
status; trouble speaking or understanding speech; visual disturbances; loss
of balance, dizziness, difculty walking; or sudden severe headache.
1. Motor Loss

Hemiplegia, hemiparesis,

Flaccid paralysis and loss of or decrease in the deep tendon reexes

(initial clinical feature) followed by (after 48 hours) reappearance of
deep reexes and abnormally increased muscle tone (spasticity).

2. Communication Loss

Dysarthria (difculty speaking),

Dysphasia (impaired speech) or aphasia (loss of speech),

Apraxia (inability to perform a previously learned action).

3. Perceptual Disturbances and Sensory Loss

Visual-perceptual dysfunctions (homonymous hemianopia [loss of half

of the visual eld),

Disturbances in visual spatial relations (perceiving the relation of two or

more objects in spatial areas), frequently seen in patients with right
hemispheric damage,

Sensory losses: slight impairment of touch or more severe with loss of

proprioception; difculty in interrupting visual, tactile, and auditory
stimuli.

4. Impaired Cognitive and Psychological Effects

Frontal lobe damage: Learning capacity, memory, or other higher

cortical intellectual functions may be impaired. Such dysfunction may
be reected in a limited attention span, difculties in comprehension,
forgetfulness, and lack of motivation,

Depression, other psychological problems: emotional lability, hostility,

frustration, resentment, and lack of cooperation.

F. Diagnostic Studies
Strokes happen fast and will often occur before an individual can be
seen by a doctor for a proper diagnosis.

The acronym F.A.S.T. is a way

to remember the signs of stroke, and
can help identify the onset of stroke
more quickly:

Face

drooping:

if

the

person tries to smile does

one side of the face droop?

Arm

weakness:

if

the

person tries to raise both

their arms does one arm
drift downward?

Speech

difficulty:

if

the

person tries to repeat a

simple phrase is their speech slurred or strange?

Time to call 911: if any of these signs are observed, contact the
emergency services.

Both ischemic strokes and hemorrhagic strokes require different kinds of

treatment. Unfortunately, it is only possible to be sure of what type of stroke
someone has had by giving them a brain scan in a hospital environment.
There are several different types of diagnostic tests that doctors can use
in order to determine which type of stroke has occurred:
1. CT

scan

(with/without

enhancement): Demonstrates

structural

abnormalities, edema, hematomas, ischemia, and infarctions. Note: May

not immediately reveal all changes, e.g., ischemic infarcts are not evident
on CT for 812 hour; however, intracerebral hemorrhage is immediately
apparent; therefore, emergency CT is always done before administering
tissue plasminogen activator (t-PA). In addition, patients with TIA
commonly have a normal CT scan.

CT scan taken some time after a large stroke. The black area is where the
stroke was and now the brain tissue has died and left a large hole.
Photo via: emedicinehealth.com
2. PET scan: Provides data on cerebral metabolism and blood flow changes,
especially in ischemic stroke.
3. MRI: Shows areas of infarction, hemorrhage, AV malformations; and
areas of ischemia.
4. Cerebral angiography: Helps determine specific cause of stroke, e.g.,
hemorrhage or obstructed artery, pinpoints site of occlusion or rupture.
Digital subtraction angiography evaluates patency of cerebral vessels,
identifies their position in head and neck, and detects/evaluates lesions
and vascular abnormalities.
5. Lumbar puncture (LP): Pressure is usually normal and CSF is clear in
cerebral thrombosis, embolism, and TIA. Pressure elevation and grossly
bloody fluid suggest subarachnoid and intracerebral hemorrhage. CSF
total protein level may be elevated in cases of thrombosis because of

inflammatory process. LP should be performed if septic embolism from

bacterial endocarditis is suspected.
6. Transcranial Doppler ultrasonography: Evaluates the velocity of blood flow
through major intracranial vessels; identifies AV disease, e.g., problems
with carotid system (blood flow/presence of atherosclerotic plaques).
7. EEG: Identifies problems based on reduced electrical activity in specific
areas of infarction; and can differentiate seizure activity from CVA
damage.
8. X-rays (skull): May show shift of pineal gland to the opposite side from an
expanding mass; calcifications of the internal carotid may be visible in
cerebral thrombosis; partial calcification of walls of an aneurysm may be
noted in subarachnoid hemorrhage.
9. Laboratory studies to rule out systemic causes: CBC, platelet and clotting
studies, VDRL/RPR, erythrocyte sedimentation rate (ESR), chemistries
(glucose, sodium).
10. ECG, chest x-ray, and echocardiography: To rule out cardiac origin as
source of embolus (20% of strokes are the result of blood or vegetative
emboli associated with valvular disease, dysrhythmias, or endocarditis).

G. Prevention
1.

Help patients alter risk factors for stroke; encourage patient to quit

smoking, maintain a healthy weight, follow a healthy diet (including

modest alcohol consumption), and exercise daily.
2.
Prepare and support patient through carotid endarterectomy.

3.

Administer

anticoagulant

agents

as

prescribed

(eg,

low

dose aspirin therapy).

6 ways to reduce your stroke risk.

Photo via:HuffingtonPost.com

H. Medical Management
1.Recombinant tissue plasminogen activator (tPA), unless contraindicated;
monitor for bleeding.
2.Anticoagulation therapy.
3.Management of increased intracranial pressure (ICP): osmotic diuretics,
maintain PaCO2 at 30 to 35 mm Hg, position to avoid hypoxia (elevate the
head of bed to promote venous drainage and to lower increased ICP).
4.Possible hemicraniectomy for increased ICP from brain edema in a very
large stroke.
5.Intubation with an endotracheal tube to establish a patent airway, if
necessary.
6.Continuous hemodynamic monitoring (the goals for blood pressure
remain controversial for a patient who has not received thrombolytic
therapy; antihypertensive treatment may be withheld unless the systolic
blood pressure exceeds mm Hg or the diastolic blood pressure exceeds
120 mm Hg).
7.Neurologic assessment

to

determine if the stroke is

evolving and if other acute
complications are developing.

I. Management

of

Complications
1.Decreased
ow:

cerebral

Pulmonary

blood
care,

maintenance of a patent airway, and administration of supplemental

oxygen as needed.
2.Monitor for UTIs, cardiac dysrhythmias, and complications of immobility.

CHAPTER III
NURSING CARE
A. Nursing Assessment
1. Acute Phase
Acute phase starts during the first three days. Weigh patient (used to
determine medication dosages), and maintain a neurologic ow sheet to
reect the following nursing assessment parameters:

Change in level of consciousness or responsiveness, ability to

speak, and orientation.

Presence or absence of voluntary or involuntary movements of the

extremities: muscle tone, body posture, and head position.

Stiffness or accidity of the neck.
Eye opening, comparative size of pupils and pupillary reactions to

light, and ocular position.

Color of face and extremities; temperature and moisture of skin.
Quality and rates of pulse and respiration; ABGs,

body temperature, and arterial pressure.

Volume of uids ingested or administered and volume of urine

excreted per 24 hours.

Signs of bleeding.
Blood pressure maintained within normal limits.

2. Postacute Phase
Assess the following functions:

Mental status (memory, attention span, perception, orientation,

affect, speech/language).

Sensation and perception (usually the patient has decreased

awareness of pain and temperature).

Motor control (upper and lower extremity movement); swallowing

ability, nutritional and hydration status, skin integrity, activity
tolerance, and bowel and bladder function.

Continue focusing nursing assessment on impairment of function

in patients daily activities.

B. Nursing Diagnoses
1.
2.
3.
4.
5.
6.
7.
8.

Ineffective Cerebral Tissue Perfusion

Impaired Physical Mobility
Impaired Verbal Communication
Disturbed Sensory Perception
Ineffective Coping
Self-Care Deficit
Risk for Impaired Swallowing
Knowledge Deficit

C. Nursing Priorities
1.
2.
3.
4.
5.

Promote adequate cerebral perfusion and oxygenation.

Prevent/minimize complications and permanent disabilities.
Assist patient to gain independence in ADLs.
Support coping process and integration of changes into self-concept.
Provide
information
about
disease
process/prognosis
and
treatment/rehabilitation needs.

D. Nursing Interventions
1. Ineffective Cerebral Tissue Perfusion
Nursing Diagnosis

Ineffective Cerebral Tissue Perfusion

May be related to

Interruption of blood flow: occlusive disorder, hemorrhage; cerebral

vasospasm, cerebral edema

Possibly evidenced by

Altered level of consciousness; memory loss

Changes in motor/sensory responses; restlessness

Sensory, language, intellectual, and emotional deficits

Changes in vital signs

Desired Outcomes

Maintain usual/improved level of consciousness, cognition, and

motor/sensory function.

Demonstrate stable vital signs and absence of signs of increased ICP.

Display no further deterioration/recurrence of deficits

Nursing Interventions
Assess factors related to individual

Rationale
Assessment will determine and

Nursing Interventions

situation for decreased cerebral

perfusion and potential for increased
ICP.

Closely assess and monitor

neurological status frequently and
compare with baseline.

Rationale
influence the choice of interventions.
Deterioration in neurological signs or
failure to improve after initial insult may
reflect decreased intracranial adaptive
capacity requiring patient to be
transferred to critical area for monitoring
of ICP, other therapies. If the stroke is
evolving, patient can deteriorate quickly
and require repeated assessment and
progressive treatment. If the stroke is
completed, the neurological deficit is
nonprogressive, and treatment is
geared toward rehabilitation and
preventing recurrence.
Assesses trends in level of
consciousness (LOC) and potential for
increased ICP and is useful in
determining location, extent, and
progression of damage. May also reveal
presence of TIA, which may warn of
impending thrombotic CVA.

Monitor vital signs:

Fluctuations in pressure may occur
because of cerebral injury in vasomotor
area of the brain. Hypertension or
postural hypotension may have been a
precipitating factor. Hypotension may
changes in blood pressure, compare BP
occur because of shock (circulatory
readings in both arms.
collapse). Increased ICP may occur
because of tissue edema or clot
formation. Subclavian artery blockage
may be revealed by difference in
pressure readings between arms.
Changes in rate, especially bradycardia,
can occur because of the brain damage.
Heart rate and rhythm, assess for
Dysrhythmias and murmurs may reflect
murmurs.
cardiac disease, which may have
precipitated CVA (stroke after MI or from
valve dysfunction).
Respirations, noting patterns and
Irregularities can suggest location of
rhythm (periods of apnea after
cerebral insult or increasing ICP and
hyperventilation), Cheyne-Stokes
need for further intervention, including
respiration.
possible respiratory support.
Evaluate pupils, noting size, shape,
Pupil reactions are regulated by the
equality, light reactivity.
oculomotor (III) cranial nerve and are
useful in determining whether the brain
stem is intact. Pupil size and equality is
determined by balance between

Nursing Interventions

Rationale
parasympathetic and sympathetic
innervation. Response to light reflects
combined function of the optic (II) and
oculomotor (III) cranial nerves.
Document changes in vision: reports of Specific visual alterations reflect area of
blurred vision, alterations in visual field, brain involved, indicate safety concerns,
depth perception.
and influence choice of interventions.
Changes in cognition and speech
Assess higher functions, including
content are an indicator of location and
speech, if patient is alert.
degree of cerebral involvement and may
indicate deterioration or increased ICP.
Reduces arterial pressure by promoting
Position with head slightly elevated and
venous drainage and may improve
in neutral position.
cerebral perfusion.
Maintain bedrest, provide quiet and
Continuous stimulation or activity can
relaxing environment, restrict visitors
increase intracranial pressure
and activities. Cluster nursing
(ICP). Absolute rest and quiet may be
interventions and provide rest periods
needed to prevent rebleeding in the
between care activities. Limit duration of
case of hemorrhage.
procedures.
Prevent straining at stool, holding
Valsalva maneuver increases ICP and
breath.
potentiates risk of rebleeding.
Indicative of meningeal irritation,
Assess for nuchal rigidity, twitching,
especially in hemorrhage disorders.
increased restlessness, irritability, onset Seizures may reflect increased ICP or
of seizure activity.
cerebral injury, requiring further
evaluation and intervention.
Reduces hypoxemia. Hypoxemia can
Administer supplemental oxygen as
cause cerebral vasodilation and
indicated.
increase pressure or edema formation.
Administer medications as indicated:
Thrombolytic agents are useful in
dissolving clot when started within 3 hr
of initial symptoms. Thirty percent are
likely to recover with little or no
disability. Treatment is based on trying
Alteplase (Activase), t-PA;
to limit the size of the infarct, and use
requires close monitoring for signs of
intracranial hemorrhage. Note: These
agents are contraindicated in cranial
hemorrhage as diagnosed by CT scan.
May be used to improve cerebral blood
Anticoagulants: warfarin sodium
flow and prevent further clotting when
(Coumadin), low-molecular-weight
embolism and/or thrombosis is the
heparin (Lovenox);
problem.
Antiplatelet agents: aspirin (ASA),
Contraindicated in hypertensive patients
dipyridamole (Persantine), ticlopidine
because of increased risk of

Nursing Interventions
(Ticlid);
Antifibrinolytics: aminocaproic acid
(Amicar);

Antihypertensives

Peripheral vasodilators: cyclandelate

(Cyclospasmol), papaverine (Pavabid),
isoxsuprine (Vasodilan).
Steroids: dexamethasone (Decadron).

Neuroprotective agents: calcium

channel blockers, excitatory amino acid
inhibitors, gangliosides.

Phenytoin (Dilantin), phenobarbital.

Stool softeners.

Rationale
hemorrhage.
Used with caution in hemorrhagic
disorder to prevent lysis of formed clots
and subsequent rebleeding.
Chronic hypertension requires cautious
treatment because aggressive
management increases the risk of
extension of tissue damage.
Transient hypertension often occurs
during acute stroke and resolves often
without therapeutic intervention.Used to
improve collateral circulation or
decrease vasospasm.
Use is controversial in control of
cerebral edema.
These agents are being researched as
a means to protect the brain by
interrupting the destructive cascade of
biochemical events (influx of calcium
into cells, release of excitatory
neurotransmitters, buildup of lactic acid)
to limit ischemic injury.
May be used to control seizures and/or
for sedative action. Note: Phenobarbital
enhances action of antiepileptics.
Prevents straining during bowel
movement and corresponding increase
of ICP.
May be necessary to resolve situation,
reduce neurological symptoms of
recurrent stroke.

Prepare for surgery, as appropriate:

endarterectomy, microvascular bypass,
cerebral angioplasty.
Monitor laboratory studies as indicated:
prothrombin time (PT) and/or activated Provides information about drug
partial thromboplastin time (aPTT) time, effectiveness and/or therapeutic level.
Dilantin level.
2. Impaired Physical Mobility
Nursing Diagnosis

Impaired Physical Mobility

May be related to

Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic

paralysis (initially); spastic paralysis

Perceptual/cognitive impairment

Possibly evidenced by

Inability to purposefully move within the physical environment; impaired

coordination; limited range of motion; decreased muscle
strength/control

Desired Outcomes

Maintain/increase strength and function of affected or compensatory

body part.

Maintain optimal position of function as evidenced by absence of

contractures, foot drop.

Demonstrate techniques/behaviors that enable resumption of activities.

Maintain skin integrity.

Nursing Interventions

Rationale
Identifies strengths and deficiencies
that may provide information regarding
Assess extent of impairment initially and
recovery. Assists in choice of
on a regular basis. Classify according to
interventions, because different
04 scale.
techniques are used for flaccid and
spastic paralysis.
Reduces risk of tissue injury. Affected
Change positions at least every 2 hr
side has poorer circulation and reduced
(supine, side lying) and possibly more
sensation and is more predisposed to
often if placed on affected side.
skin breakdown.
Helps maintain functional hip extension;
Position in prone position once or twice
however, may increase anxiety,
a day if patient can tolerate.
especially about ability to breathe.
Prevents contractures and footdrop and
Prop extremities in functional position; facilitates use when function returns.
use footboard during the period of
Flaccid paralysis may interfere with
flaccid paralysis. Maintain neutral
ability to support head, whereas spastic
position of head.
paralysis may lead to deviation of head
to one side.
During flaccid paralysis, use of sling
Use arm sling when patient is in upright
may reduce risk of shoulder subluxation
position, as indicated.
and shoulder-hand syndrome.
Flexion contractures occur because
Evaluate need for positional aids and/or
flexor muscles are stronger than
splints during spastic paralysis:
extensors.
Prevents adduction of shoulder and
Place pillow under axilla to abduct arm
flexion of elbow.
Promotes venous return and helps
Elevate arm and hand
prevent edema formation.
Place hard hand-rolls in the palm with Hard cones decrease the stimulation of
fingers and thumb opposed.
finger flexion, maintaining finger and

Nursing Interventions
Place knee and hop in extended
position;
Maintain leg in neutral position with a
trochanter roll;
Discontinue use of footboard, when
appropriate.

Rationale
thumb in a functional position.
Maintains functional position.
Prevents external hip rotation.
Continued use (after change from
flaccid to spastic paralysis) can cause
excessive pressure on the ball of the
foot, enhance spasticity, and actually
increase plantar flexion.

Observe affected side for color, edema,

Edematous tissue is more easily
or other signs of compromised
traumatized and heals more slowly.
circulation.
Pressure points over bony prominences
Inspect skin regularly, particularly over
are most at risk for decreased
bony prominences. Gently massage any
perfusion. Circulatory stimulation and
reddened areas and provide aids such
padding help prevent skin breakdown
as sheepskin pads as necessary.
and decubitus development.
Minimizes muscle atrophy, promotes
Begin active or passive ROM to all
circulation, helps prevent contractures.
extremities (including splinted) on
Reduces risk of hypercalciuria and
admission. Encourage exercises such
osteoporosis if underlying problem is
as quadriceps/gluteal exercise,
hemorrhage. Note: Excessive
squeezing rubber ball, extension of
stimulation can predispose to
fingers and legs/feet.
rebleeding.
Assist patient with exercise and perform
ROM exercises for both the affected
and unaffected sides. Teach and
encourage patient to use his unaffected
side to exercise his affected side.
Assist patient to develop sitting balance
by raising head of bed, assist to sit on
edge of bed, having patient to use the
strong arm to support body weight and
Aids in retraining neuronal pathways,
move using the strong leg. Assist to
enhancing proprioception and motor
develop standing balance by putting flat
response.
walking shoes, support patients lower
back with hands while positioning own
knees outside patients knees, assist in
using parallel bars.
Helps stabilize BP (by restoring
vasomotor tone), promotes
maintenance of extremities in a
Get patient up in chair as soon as vital
functional position and emptying of
signs are stable, except following
bladder, reducing risk of urinary stones
cerebral hemorrhage.
and infections from stasis. Note: If
stroke is not completed, activity
increases risk of additional bleed.

Nursing Interventions
Pad chair seat with foam or water-filled
cushion, and assist patient to shift
weight at frequent intervals.
Set goals with patient and SO for
participation in activities and position
changes.
Encourage patient to assist with
movement and exercises using
unaffected extremity to support and
move weaker side.

Rationale
To prevent pressure on the coccyx and
skin breakdown.

Promotes sense of expectation of

improvement, and provides some sense
of control and independence.
May respond as if affected side is no
longer part of body and needs
encouragement and active training to
reincorporate it as a part of own body.
Promotes even weight distribution,
decreasing pressure on bony points and
helping to prevent skin breakdown and
Provide egg-crate mattress, water bed, decubitus formation. Specialized beds
flotation device, or specialized beds, as help with positioning, enhance
indicated.
circulation, and reduce venous stasis to
decrease risk of tissue injury and
complications such as orthostatic
pneumonia.
Position the patient and align his
extremities correctly. Use high-top
sneakers to prevent footdrop and
These are measures to prevent
contracture and convoluted foam,
pressure ulcers.
flotation, or pulsating mattresses or
sheepskin.
3. Impaired Verbal Communication
Nursing Diagnosis

Communication, impaired verbal [and/or written]

May be related to

Impaired cerebral circulation; neuromuscular impairment, loss of

facial/oral muscle tone/control; generalized weakness/fatigue

Possibly evidenced by

Impaired articulation; does not/cannot speak (dysarthria)

Inability to modulate speech, find and name words, identify objects;

inability to comprehend written/spoken language

Inability to produce written communication

Desired Outcomes

Indicate an understanding of the communication problems.

Establish method of communication in which needs can be expressed.

Use resources appropriately.

Nursing Interventions

Rationale
Helps determine area and degree of
brain involvement and difficulty patient
has with any or all steps of the
communication process. Patient may
have receptive aphasia or damage to
the Wernickes speech area which is
characterized by difficulty of
understanding spoken words. He may
also have expressive aphasia or
damage to the Brocas speech areas,
which is difficulty in speaking words
correctly, or may experience both.
Assess extent of dysfunction: patient
Choice of interventions depends on type
cannot understand words or has trouble
of impairment. Aphasia is a defect in
speaking or making self understood.
using and interpreting symbols of
Differentiate aphasia from dysarthria.
language and may involve sensory
and/or motor components (inability to
comprehend written and/or spoken
words or to write, make signs, speak). A
dysarthric person can understand,
read, and write language but has
difficulty forming and pronouncing words
because of weakness and paralysis of
oral musculature. Patient may lose
ability to monitor verbal output and be
unaware that communication is not
sensible.
Feedback helps patient realize why
Listen for errors in conversation and
caregivers are not understanding or
provide feedback.
responding appropriately and provides
opportunity to clarify meaning.
Ask patient to follow simple commands
(Close and open your eyes, Raise
Tests for receptive aphasia.
your hand); repeat simple words or
sentences;
Tests for expressive aphasia. Patient
Point to objects and ask patient to name
may recognize item but not be able to
them.
name it.
Have patient produce simple sounds
Identifies dysarthria, because motor
(Dog, meow, Shh).
components of speech (tongue, lip
movement, breath control) can affect

Nursing Interventions

Rationale
articulation and may or may not be
accompanied by expressive aphasia.
Tests for writing disability (agraphia) and
Ask patient to write his name and a
deficits in reading comprehension
short sentence. If unable to write, have
(alexia), which are also part of receptive
patient read a short sentence.
and expressive aphasia.
Write a notice at the nurses station and
patients room about speech
Allays anxiety related to inability to
impairment. Provide a special call bell communicate and fear that needs will
that can be activated by minimal
not be met promptly.
pressure if necessary.
Provides communication needs of
Provide alternative methods of
patient based on individual situation and
communication: writing, pictures.
underlying deficit.
Helpful in decreasing frustration when
Anticipate and provide for patients
dependent on others and unable to
needs.
communication desires.
Reduces confusion and allays anxiety at
having to process and respond to large
Talk directly to patient, speaking slowly
amount of information at one time. As
and distinctly. Phrase questions to be
retraining progresses, advancing
answered simply by yes or no. Progress
complexity of communication stimulates
in complexity as patient responds.
memory and further enhances word and
idea association.
Patient is not necessarily hearing
impaired, and raising voice may irritate
Speak in normal tones and avoid talking
or anger patient. Forcing responses can
too fast. Give patient ample time to
result in frustration and may cause
respond. Avoid pressing for a response.
patient to resort to automatic speech
(garbled speech, obscenities).
It is important for family members to
Encourage SO/visitors to persist in
continue talking to patient to reduce
efforts to communicate with patient:
patients isolation, promote
reading mail, discussing family
establishment of effective
happenings even if patient is unable to
communication, and maintain sense of
respond appropriately.
connectedness with family.
Discuss familiar topics, e.g., weather,
Promotes meaningful conversation and
family, hobbies, jobs.
provides opportunity to practice skills.
Respect patients preinjury capabilities; Enables patient to feel esteemed,
avoid speaking down to patient or
because intellectual abilities often
making patronizing remarks.
remain intact.
Assesses individual verbal capabilities
Consult and refer patient to speech
and sensory, motor, and cognitive
therapist.
functioning to identify deficits/therapy
needs.
4. Disturbed Sensory Perception

Nursing Diagnosis

Disturbed Sensory Perception

May be related to

Altered sensory reception, transmission, integration (neurological

trauma or deficit)

Psychological stress (narrowed perceptual fields caused by anxiety)

Possibly evidenced by

Disorientation to time, place, person

Change in behavior pattern/usual response to stimuli; exaggerated

emotional responses

Poor concentration, altered thought processes/bizarre thinking

Reported/measured change in sensory acuity: hypoparesthesia;

altered sense of taste/smell

Inability to tell position of body parts (proprioception)

Inability to recognize/attach meaning to objects (visual agnosia)

Altered communication patterns

Motor incoordination

Desired Outcomes

Regain/maintain

usual

level

of

consciousness

and

perceptual

functioning.

Acknowledge changes in ability and presence of residual involvement.

Demonstrate behaviors to compensate for/overcome deficits.

Nursing Interventions

Rationale
Awareness on the type and areas of
Review pathology of individual
involvement aid in assessing specific
condition.
deficit and planning of care.
Observe behavioral responses: crying, Individual responses are variable, but
inappropriate affect, agitation, hostility, commonalities such as emotional
agitation, hallucination.
lability, lowered frustration threshold,
apathy, and impulsiveness may

Nursing Interventions

Rationale
complicate care.

Establish and maintain communication

with the patient. Set up a simple method
of communicating basic needs.
Note: even an unresponsive patient
Remember to phrase your questions so may be able to hear, so dont say
hell be able to answer using this
anything in his presence you wouldnt
system. Repeat yourself quietly and
want him to hear and remember.
calmly and use gestures when
necessary to help in understanding.
Reduces anxiety and exaggerated
Eliminate extraneous noise and stimuli
emotional responses and confusion
as necessary.
associated with sensory overload.
Patient may have limited attention span
Speak in calm, comforting, quiet voice,
or problems with comprehension. These
using short sentences. Maintain eye
measures can help patient attend to
contact.
communication.
Assists patient to identify
Ascertain patients perceptions.
inconsistencies in reception and
Reorient patient frequently to
integration of stimuli and may reduce
environment, staff, procedures.
perceptual distortion of reality.
Presence of visual disorders can
Evaluate for visual deficits. Note loss of
negatively affect patients ability to
visual field, changes in depth perception
perceive environment and relearn motor
(horizontal and/or vertical planes),
skills and increases risk of accident and
presence of diplopia (double vision).
injury.
Helps the patient to recognize the
Approach patient from visually intact
presence of persons or objects and may
side. Leave light on; position objects to help with depth perception problems.
take advantage of intact visual fields.
This also prevents patient from being
Patch affected eye if indicated.
startled. Patching the eye may decrease
sensory confusion of double vision.
Diminished sensory awareness and
impairment of kinesthetic sense
Assess sensory awareness: dull from
negatively affects
sharp, hot from cold, position of body
balance and positioning and
parts, joint sense.
appropriateness of movement, which
interferes with ambulation, increasing
risk of trauma.
Aids in retraining sensory pathways to
Stimulate sense of touch. Give patient
integrate reception and interpretation of
objects to touch, and hold. Have patient
stimuli. Helps patient orient self spatially
practice touching walls boundaries.
and strengthens use of affected side.
Protect from temperature extremes;
assess environment for hazards.
Promotes patient safety, reducing risk of
Recommend testing warm water with
injury.
unaffected hand.
Note inattention to body parts,
Agnosia, the loss of comprehension of

Nursing Interventions

Rationale
auditory, visual, or other sensations,
may lead result to unilateral neglect,
segments of environment, lack of
inability to recognize environmental
recognition of familiar objects/persons.
cues, considerable self-care deficits,
and disorientation or bizarre behavior.
Encourage patient to watch feet when
appropriate and consciously position
Use of visual and tactile stimuli assists
body parts. Make patient aware of all
in reintegration of affected side and
neglected body parts: sensory
allows patient to experience forgotten
stimulation to affected side, exercises
sensations of normal movement
that bring affected side across midline,
patterns.
reminding person to dress/care for
affected (blind) side.
5. Ineffective Coping
Nursing Diagnosis

Ineffective Coping

May be related to

Situational crises, vulnerability, cognitive perceptual changes

Possibly evidenced by

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

Desired Outcomes

Verbalize acceptance of self in situation.

Talk/communicate with SO about situation and changes that have

occurred.

Verbalize awareness of own coping abilities.

Meet psychological needs as evidenced by appropriate expression of

feelings, identification of options, and use of resources.

Nursing Interventions
Assess extent of altered perception and
related degree of disability. Determine
Functional Independence Measure
score.
Identify meaning of the dysfunction and

Rationale
Determination of individual factors aids
in developing plan of care/choice of
interventions and discharge
expectations.
Independence is highly valued in

Nursing Interventions

change to patient. Note ability to

understand events, provide realistic
appraisal of the situation.

Determine outside stressors: family,

work, future healthcare needs.

Rationale
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 problemsolving, healthcare providers need to
understand the meaning of the
stroke/limitations to patient.
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.

Provide psychological support and set

realistic short-term goals. Involve the
To increase the patients sense of
patients SO in plan of care when
confidence and can help in compliance
possible and explain his deficits and
to therapeutic regimen.
strengths.
Encourage patient to express feelings, Demonstrates acceptance of patient in
including hostility or anger, denial,
recognizing and beginning to deal with
depression, sense of disconnectedness. these feelings.
Suggests rejection of body part and
Note whether patient refers to affected
negative feelings about body image and
side as it or denies affected side and
abilities, indicating need for intervention
says it is dead.
and emotional support.
Acknowledge statement of feelings
about betrayal of body; remain matterHelps patient see that the nurse accepts
of-fact about reality that patient can still
both sides as part of the whole
use unaffected side and learn to control
individual. Allows patient to feel hopeful
affected side. Use words (weak,
and begin to accept current situation.
affected, right-left) that incorporate that
side as part of the whole body.
Identify previous methods of dealing
Provides opportunity to use behaviors
with life problems. Determine
previously effective, build on past
presence of support systems.
successes, and mobilize resources.
Consolidates gains, helps reduce
Emphasize small gains either in
feelings of anger and helplessness, and
recovery of function or independence.
conveys sense of progress.
Support behaviors and efforts such as Suggest possible adaptation to changes
increased interest/participation in
and understanding about own role in
rehabilitation activities.
future lifestyle.
Monitor for sleep disturbance, increased May indicate onset of depression
difficulty concentrating, statements of
(common after effect of stroke), which
inability to cope, lethargy, withdrawal.
may require further evaluation and

Nursing Interventions

Rationale
intervention.
May facilitate adaptation to role
changes that are necessary for a sense
of feeling/being a productive
Refer for neuropsychological evaluation person. Note: Depression is common in
and/or counseling if indicated.
stroke survivors and may be a direct
result of the brain damage and/or an
emotional reaction to sudden-onset
disability.
6. Self-Care Deficit
Nursing Diagnosis

Self-Care Deficit

May be related to

Neuromuscular impairment, decreased strength and endurance, loss of

muscle control/coordination

Perceptual/cognitive impairment

Pain/discomfort

Depression

Possibly evidenced by

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

Desired Outcomes

Demonstrate techniques/lifestyle changes to meet self-care needs.

Perform self-care activities within level of own ability.

Identify personal/community resources that can provide assistance as

needed.

Nursing Interventions
Rationale
Assess abilities and level of deficit (04 Aids in planning for meeting individual
scale) for performing ADLs.
needs.
To maintain self-esteem and promote
recovery, it is important for the patient to
Avoid doing things for patient that
do as much as possible for self. These
patient can do for self, but provide
patients may become fearful and
assistance as necessary.
independent, although assistance is
helpful in preventing frustration.
May indicate need for additional
Be aware of impulsive actions
interventions and supervision to
suggestive of impaired judgment.
promote patient safety.
Maintain a supportive, firm attitude.
Patients need empathy and to know
Allow patient sufficient time to
caregivers will be consistent in their
accomplish tasks. Dont rush the
assistance.
patient.
Enhances sense of self-worth, promotes
Provide positive feedback for efforts and
independence, and encourages patient
accomplishments.
to continue endeavors.
Create plan for visual deficits that are
Patient will be able to see to eat the
present: Place food and utensils on the food. Will be able to see when getting
tray related to patients unaffected side; in/out of bed and observe anyone who
Situate the bed so that patients
comes into the room. Provides for
unaffected side is facing the room with safety when patient is able to move
the affected side to the wall; Position
around the room, reducing risk of
furniture against wall/out of travel path. tripping/falling over furniture.
Provide self-help devices: extensions
To enable the patient to manage for self,
with hooks for picking things up from the
enhancing independence and selffloor, toilet risers, long-handled
esteem, reduce reliance on others for
brushes, drinking straw, leg bag for
meeting own needs, and enables the
catheter, shower chair. Encourage good
patient to be more socially active.
grooming and makeup habits.
Reestablishes sense of independence
and fosters self-worth and enhances
rehabilitation process. Note: This may
Encourage SO to allow patient to do as
be very difficult and frustrating for the
much as possible for self.
caregiver, depending on degree of
disability and time required for patient to
complete activity.
Patient may have neurogenic bladder,
Assess patients ability to communicate
be inattentive, or be unable to
the need to void and/or ability to use
communicate needs in acute recovery
urinal, bedpan. Take patient to the
phase, but usually is able to regain
bathroom at periodic intervals for
independent control of this function as
voiding if appropriate.
recovery progresses.
Identify previous bowel habits and
Assists in development of retraining
reestablish normal regimen. Increase
program (independence) and aids in
bulk in diet, encourage fluid intake,
preventing constipation and impaction
increased activity.
(long-term effects).

Nursing Interventions
Teach the patient to comb hair, dress,
and wash.
Refer patient to physical and
occupational therapist.

Rationale
To promote sense o f independence and
self-esteem.
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.

7. Risk for Impaired Swallowing

Nursing Diagnosis

Risk for Impaired Swallowing

Risk factors may include

Neuromuscular/perceptual impairment

Desired Outcomes

Demonstrate feeding methods appropriate to individual situation with

aspiration prevented.

Maintain desired body weight.

Nursing Interventions
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.
Have suction equipment available at
bedside, especially during early feeding
efforts.
Promote effective swallowing: Schedule
activities and medications to provide a
minimum of 30 min rest before eating.
Provide pleasant and unhurried
environment free of distractions.
Assist patient with head control, and
position based on specific dysfunction.

Rationale

Nutritional interventions and choices of

feeding route are determined by these
factors.

Timely intervention may limit untoward

effect of aspiration.
Promotes optimal muscle function,
helps to limit fatigue.
Promotes relaxation and allows patient
to focus on task of eating.
Counteracts hyperextension, aiding in
prevention of aspiration and enhancing
ability to swallow. Optimal positioning
can facilitate intake and reduce risk of

Nursing Interventions

Rationale
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

Increases salivation, improving bolus
juice, etc. according to patients
formation and swallowing effort.
preference, within dietary restrictions;
Lukewarm temperatures are less likely
to stimulate salivation so foods and
Serve foods at customary temperature
fluids should be served cold or warm as
and water always chilled.
appropriate. Note: Water is the most
difficult to swallow.
Stimulate lips to close or manually open
Aids in sensory retraining and promotes
mouth by light pressure on lips or under
muscular control.
the chin if needed.
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,
Place food of appropriate consistency in whereas patients with delayed
unaffected side of mouth.
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.
Can improve tongue movement and
Touch parts of the cheek with tongue
control (necessary for swallowing), and
blade and apply ice to weak tongue.
inhibits tongue protrusion.
Feed slowly, allowing 3045 min for
Feeling rushed can increase stress and

Nursing Interventions

Rationale
level of frustration, may increase risk of
meals.
aspiration, and may result in patients
terminating meal early.
Prevents patient from swallowing food
Offer solid foods and liquids at different before it is thoroughly chewed. In
times.
general, liquids should be offered only
after patient has finished eating foods.
Although use may strengthen facial and
swallowing muscles, if patient lacks tight
Limit or avoid use of drinking straw for
lip closure to accommodate straw or if
liquids;
liquid is deposited too far back in mouth,
risk of aspiration may be increased.
Provides familiar tastes and
Encourage SO to bring favorite foods. preferences. Stimulates feeding efforts
and may enhance swallowing or intake.
Maintain upright position for 4560 min Helps patient manage oral secretions
after eating.
and reduces risk of regurgitation.
Alternative methods of feeding may be
Maintain accurate I&O; record calorie
used if swallowing efforts are not
count.
sufficient to meet fluid and nutritional
needs.
May increase release of endorphins in
Encourage participation in exercise
the brain, promoting a sense of general
program.
well-being and increasing appetite.
May be necessary for fluid replacement
Administer IV fluids and/or tube
and nutrition if patient is unable to take
feedings
anything orally.
Inclusion of dietitian, speech and
Coordinate multidisciplinary approach to occupational therapists can increase
develop treatment plan that meets
effectiveness of long-term plan and
individual needs.
significantly reduce risk of silent
aspiration.
8. Knowledge Deficit
Nursing Diagnosis

Knowledge Deficit

May be related to

Lack of exposure; unfamiliarity with information resources

Cognitive limitation, information misinterpretation, lack of recall

Possibly evidenced by

Request for information

Statement of misconception

Inaccurate follow-through of instructions

Development of preventable complications

Desired Outcomes

Participate in learning process.

Verbalize

understanding

of

condition/prognosis

and

potential

complications.

Verbalize understanding of therapeutic regimen and rationale for

actions.

Initiate necessary lifestyle changes.

Nursing Interventions

Rationale
This will affect the choice of teaching
Assess type and degree of sensory
methods and content complexity of
perceptual involvement.
instruction.
These individuals will be providing
support/care and have great impact on
Include SO and/or family in discussions patients quality of life.These people will
and teaching.
be providing support and care thus will
have a great impact on the patients
quality of life and home health-care.
Aids in establishing realistic
Discuss specific pathology and
expectations and promotes
individual potentials.
understanding of current situation and
needs.
Identify signs and symptoms requiring
further follow-up: changes or decline in Prompt evaluation and intervention
visual, motor, sensory functions;
reduces risk of complications and
alteration in mentation or behavioral
further loss of function.
responses; severe headache.
Review current restrictions and discuss Promotes understanding, provides hope
potential resumption of activities
for future, and creates expectation of
(including sexual relations).
resumption of more normal life.
Recommended activities, limitations,
and medication and/or therapy needs
are established on the basis of a
Reinforce current therapeutic regimen,
coordinated interdisciplinary approach.
including use of medications to control
Follow-through is essential to
hypertension, hypercholesterolemia,
progression of recovery and prevention
diabetes, as indicated; aspirin or similarof complications. Note: Long-term
acting drugs, for example, ticlopidine
anticoagulation may be beneficial for
(Ticlid), warfarin sodium (Coumadin).
patients older than 45 years of age who
Identify ways of continuing program
are prone to clot formation; however,
after discharge.
use of these drugs is not effective for
CVA resulting from vascular aneurysm
or vessel rupture.

Nursing Interventions
Provide written instructions and
schedules for activity, medication,
important facts.
Encourage patient to refer to written
communications or notes instead of
depending on memory.

Rationale
Provides visual reinforcement and
reference source after discharge.

Provides aids to support memory and

promotes improvement in cognitive
skills.
Varying levels of assistance may be
Discuss plans for meeting self-care
need to be planned for based on
needs.
individual situation.
Home environment may require
Refer to home care supervisor or a
evaluation and modifications to meet
visiting nurse.
individual needs.
Suggest patient reduce environmental Multiple stimuli may aggravate
stimuli, especially during cognitive
confusion, overwhelm the patient, and
activities.
impair mental abilities.
Some patients (especially those with
Recommend patient seek assistance in right CVA) may display impaired
problem-solving process and validate
judgment and impulsive behavior,
decisions, as indicated.
compromising ability to make sound
decisions.
Identify individual risk factors (e.g.,
hypertension, cardiac dysrhythmias,
Promotes general well-being and may
obesity, smoking, heavy alcohol use,
reduce risk of recurrence. Note: Obesity
atherosclerosis, poor control of
in women has been found to have a
diabetes, use of oral contraceptives)
high correlation with ischemic stroke.
and discuss necessary lifestyle
changes.
Review importance of balanced diet,
low in cholesterol and sodium if
Improves general health and well-being
indicated. Discuss role of vitamins and and provides energy for life activities.
other supplements.
Reinforce importance of follow-up care
Consistent work may eventually lead to
by rehabilitation team: physical and
minimized or overcoming of residual
occupational therapists, vocational
deficits.
therapists, speech therapist, dietician.

E. Evaluation
Expected Patient Outcomes
1. Achieves improved mobility.
2. Has no complaint of pain.
3. Achieves self-care; performs hygiene care; uses adaptive equipment.
4. Demonstrates techniques to compensate for altered sensory reception,
such as turning the head to see people or objects.
5. Demonstrates safe swallowing.

6. Achieves normal bowel and bladder elimination.

7. Participates in cognitive improvement program.
8. Demonstrates improved communication.
9. Maintains intact skin without breakdown.
10. Family

members

demonstrate

positive

attitude

and

coping

mechanisms.
11. Develops alternative approaches to sexual expression.

F. Discharge Goals
1

Cerebral function improved, neurological deficits resolving/stabilized.

Complications prevented or minimized.

ADL needs met by self or with assistance of other(s).

Coping with situation in positive manner, planning for the future.

Disease process/prognosis and therapeutic regimen understood.

Plan in place to meet needs after discharge.

REFERENCES
Books, Nanda. (2012). Internet. CVA Stroke Definitions and Nursing Diagnosis.
Website:

http://www.nanda-books.com/2012/10/cva-stroke-definition-and-

nursing.html . Accesed on May 3, 2016 at 20.20 pm.

Matt Vera, RN. (2012). Internet. Cerebrovascular Accident (Stroke). Website:
http://nurseslabs.com/cerebrovascular-accident-nursing-management/

Accesed on May 3, 2016 at 20.35 pm.

McIntosh, James. (2016). Internet. Articles Stroke: Causes, Symptoms,
Diagnosis and Treatment Reviewed by Dr Helen webberley. Website:
http://www.medicalnewstoday.com/articles/7624.php . Accesed on May 3,
2016 at 20.35 pm.
National Stroke Association http://www.stroke.org
NIH

Senior

Health.

(2013).

Internet.

About

Stroke.

Website:

http://nihseniorhealth.gov/stroke/aboutstroke/01.html . Accesed on May 3,

2016 at 20.25 pm.