Stroke

A stroke (cerebrovascular accident, CVA, cerebral vascular accident or brain attack) occurs

when a part of the brain is damaged or destroyed because it is deprived of blood.

Are there different types of strokes?

Ischaemic stroke

Ischaemic stroke is the most common type of stroke and is caused by a blockage of the blood

vessels supplying the brain. This may be due to ‘hardening’ and narrowing of the arteries

(atherosclerosis) or by a blood clot blocking a blood vessel.

One type of ischaemic stroke is a thrombotic stroke. This is caused by a blood clot (thrombus) in

one of the arteries of the head or neck, which severely reduces the blood flow. The thrombus

may be a result of a build-up of fatty deposits (plaques) in the blood vessels.

Another type of ischaemic stroke is an embolic stroke (or cerebral embolism), caused when a

blood clot that forms elsewhere in the body (for example, the chambers of the heart) travels

through the circulatory system to the brain. The travelling clot is called an embolus.

Haemorrhagic stroke

The most severe type of stroke is a haemorrhagic stroke. It occurs when a blood vessel in the

brain bursts, allowing blood to leak and cause damage to an area of the brain. There are 2 types:

subarachnoid haemorrhage, which occurs in the space around the brain; and an intracerebral

haemorrhage, the more common type, which involves bleeding within the brain tissue itself.

The warning signs

Sudden weakness or numbness of the face, arm and leg on one side of the body.

Loss of speech, or difficulty talking.

Dimness or loss of vision.

Unexplained dizziness, especially when associated with any of the above signs.

Unsteadiness or sudden falls.

Headache (usually severe and of sudden onset).

Confusion.

What are the risk factors for a stroke?

The older you get, the greater the risk of having a stroke, however, a significant number of young

and middle-aged people also have strokes. Men are also more likely to have a stroke, as are

people with diabetes. People who have had a previous stroke are also more likely to have another

one.

Cigarette smoking, excessive alcohol intake, being overweight and raised blood cholesterol

increase the risk of high blood pressure and artery disease, which in turn increase the risk of

having a stroke. Stroke is a vascular disease, and so shares many risk factors with coronary

vascular disease (also known as coronary artery disease).

Another risk factor is a type of irregular heartbeat known as atrial fibrillation (AF). Also, some

medications can increase stroke risk.

How is a stroke diagnosed?

Confirmation of diagnosis and initial treatment of strokes almost always takes place in a hospital.

An early diagnosis is made by evaluating symptoms, reviewing your medical history and

conducting tests.

Tests that may be recommended

Computerised tomography (CT) scan: a special X-ray which produces 2- or 3-dimensional

pictures of any part of the body.

Magnetic resonance imaging (MRI) scan: this test uses a large magnet, low-energy radio waves

and a computer to produce 2- or 3-dimensional pictures of the body.

Rehabilitation may consist of various types of therapy including:

physiotherapy to improve muscle control, co-ordination and balance;

speech therapy to retrain facial muscles and language, and help with feeding and swallowing

disorders; and

occupational therapy to improve hand–eye co-ordination and skills needed for daily living tasks,

such as bathing and cooking.

Family is also important in the rehabilitation process. Family members will probably be asked to

help the person regain lost skills by encouraging them to use the affected arm or leg, helping

them with their speech or teaching them how to do tasks which may have been forgotten, such as

combing their hair or using a cup, knife and fork.

Risk Factors

Controllable Risk Factors:

High Blood Pressure

Atrial Fibrillation

High Cholesterol

Diabetes

Atherosclerosis

Circulation Problems

Tobacco Use and Smoking

Alcohol Use

Physical Inactivity

Obesity

Uncontrollable Risk Factors:

Age

Gender

Race

Family History

Previous Stroke or TIA

Fibromuscular Dysplasia

Patent Foramen Ovale (PFO or Hole in the Heart)

PA

After checking your vital signs, doctors will examine you in a variety of ways. Having a physical

exam is the starting point for next steps, including important imaging and blood tests.

A full physical exam will allow the doctor to see if your body is reacting the way it

would if you were having a stroke.

Checking your vital signs includes the medical ABCs:

Airway. Your doctor will check to be sure that you can breathe easily and that

nothing is obstructing your airway.

Breathing. Your doctor will check to be sure you are breathing at a normal rate

of 12 to 18 breaths each minute.

Circulation. Your doctor will take your pulse, which should be between 60 and

80 beats per minute.

As part of the physical exam, the doctor will also:

Perform an eye exam to see if there is any swelling of the optic nerve, which

could be caused by pressure building up in the brain from a stroke, and for

abnormal eye movement or reflexes.

Examine your neck to listen to the carotid arteries for a bruit, a noise that

indicates build-up and a potential blockage in the arteries.

Take your blood pressure to see if it’s higher than normal (over 120/80 mm).

Take your body temperature to see if it’s between 97.8 and 99.1 degrees

Fahrenheit.

Listen to your heart and lungs for any abnormalities.

Other tests during the physical exam will check your reflexes, strength, coordination,

and your sense of touch. All of these things are commonly affected by damage done to

the brain because of a stroke, so any abnormalities in your reactions may indicate that

a stroke has occurred.

The physical exam will also include a series of questions to check for any impairment

to speech, memory, and comprehension.

DX:

Your doctor will check your blood pressure and use a stethoscope to listen to your

heart and to listen for a whooshing sound (bruit) over your neck (carotid) arteries,

which may indicate atherosclerosis. Your doctor may also use an ophthalmoscope to

check for signs of tiny cholesterol crystals or clots in the blood vessels at the back of

your eyes.

Blood tests. You may have several blood tests, which tell your care team how fast

your blood clots, whether your blood sugar is abnormally high or low, whether critical

blood chemicals are out of balance, or whether you may have an infection. Care

providers will manage your blood's clotting time and levels of sugar and key

chemicals as part of your stroke care.

Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a

detailed image of your brain. A CT scan can show a hemorrhage, tumors, strokes and

other conditions. Doctors may inject a dye into your bloodstream to view your blood

vessels in your neck and brain in greater detail (computerized tomography

angiography).

Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets

to create a detailed view of your brain. An MRI can detect brain tissue damaged by an

ischemic stroke and brain hemorrhages. Your doctor may inject a dye into a blood

vessel to view the arteries and veins and highlight blood flow (magnetic resonance

angiography, or magnetic resonance venography).

Carotid ultrasound. In this test, sound waves create detailed images of the inside of the

carotid arteries in your neck. This test shows buildup of fatty deposits (plaques) and

blood flow in your carotid arteries.

Cerebral angiogram. In this test, your doctor inserts a thin, flexible tube (catheter)

through a small incision, usually in your groin, and guides it through your major

arteries and into your carotid or vertebral artery. Then your doctor injects a dye into

your blood vessels to make them visible under X-ray imaging. This procedure gives a

detailed view of arteries in your brain and neck.

Echocardiogram. An echocardiogram uses sound waves to create detailed images of

your heart. An echocardiogram can find a source of clots in your heart that may have

traveled from your heart to your brain and caused your stroke.

You may have a transesophageal echocardiogram. In this test, your doctor inserts a

flexible tube with a small device (transducer) attached into your throat and down into

the tube that connects the back of your mouth to your stomach (esophagus). Because

your esophagus is directly behind your heart, a transesophageal echocardiogram can

create clear, detailed ultrasound images of your heart and any blood clots.

Meds:

Your doctor will probably prescribe several medicines after you have had

a stroke. Medicines to prevent blood clots are typically used,

because blood clots can cause TIAs and strokes.

The types of medicines that prevent clotting are:

Anticoagulant medicines.

Antiplatelet medicines.

Cholesterol-lowering and blood-pressure–lowering medicines are also used to

prevent TIAs and strokes.

Anticoagulant medicines

Anticoagulants such as warfarin (for example, Coumadin) prevent blood clots

from forming and keep existing blood clots from getting bigger.

You may need to take this type of medicine after a stroke if you have atrial

fibrillation or another condition that makes you more likely to have another

stroke. For more information, see the topic Atrial Fibrillation.

Antiplatelet medicines

Antiplatelet medicines keep platelets in the blood from sticking together.

Aspirin (for example, Bayer) is most often used to prevent TIAs and strokes.

Aspirin combined with dipyridamole (Aggrenox) is a safe and effective

alternative to aspirin.

Clopidogrel (Plavix) may be used for people who cannot take aspirin.

Blood Thinners Other Than Warfarin: Taking Them Safely

Statins

Statinslower cholesterol and can greatly reduce your risk of having another

stroke.Statins even protect against stroke in people who do not have heart

disease or high cholesterol.2

Blood pressure medicines

If you have high blood pressure, your doctor may want you to take medicines

to lower it. Blood pressure medicines include:

Angiotensin II receptor blockers (ARBs).

Angiotensin-converting enzyme (ACE) inhibitors.

Beta-blockers.

Calcium channel blockers.

Diuretics.

Other medicines

Medicines used to treat depression and pain may also be prescribed after a

stroke.

nursing interventions for

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

Determine factors related to individual situation/cause for coma/decreased cerebral

perfusion and potential for increased ICP.

Monitor/document neurological status frequently and compare with baseline.

Monitor vital signs, i.e., note:

Hypertension/hypotension, compare BP readings in both arms;

Heart rate and rhythm; auscultate for murmurs;

Respirations, noting patterns and rhythm, e.g., periods of apnea after hyperventilation, Cheyne-

Stokes respiration.

Evaluate pupils, noting size, shape, equality, light reactivity.

Document changes in vision, e.g., reports of blurred vision, alterations in visual

field/depth perception.

Assess higher functions, including speech, if patient is alert.

Position with head slightly elevated and in neutral position.

Maintain bedrest; provide quiet environment; restrict visitors/activities as indicated.

Provide rest periods between care activities, limit duration of procedures.

Prevent straining at stool, holding breath.

Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure

activity.

Administer supplemental oxygen as indicated.

2. 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

Assess functional ability/extent of impairment initially and on a regular basis. Classify

according to 0–4 scale.

Change positions at least every 2 hr (supine, sidelying) and possibly more often if placed

on affected side.

Position in prone position once or twice a day if patient can tolerate.

Prop extremities in functional position; use

footboard during the period of flaccid

paralysis. Maintain neutral position of head.

Prevents contractures/footdrop and facilitates use

when/if function returns. Flaccid paralysis may interfere

with ability to support head, whereas spastic paralysis

may lead to deviation of head to one side.

Use arm sling when patient is in upright

position, as indicated.

During flaccid paralysis, use of sling may reduce risk

of shoulder subluxation and shoulder-hand syndrome.

Evaluate use of/need for positional aids

and/or splints during spastic paralysis:Place

pillow under axilla to abduct arm;Elevate

arm and hand;

Flexion contractures occur because flexor muscles are

stronger than extensors.Prevents adduction of shoulder

and flexion of elbow.Promotes venous return and helps

prevent edema formation.

Place hard hand-rolls in the palm with

fingers and thumb opposed;

Hard cones decrease the stimulation of finger flexion,

maintaining finger and thumb in a functional position.

Place knee and hop in extended position; Maintains functional position.

Maintain leg in neutral position with a

trochanter roll; Prevents external hip rotation.

Discontinue use of footboard, when

appropriate.

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, or

other signs of compromised circulation.

Edematous tissue is more easily traumatized and heals

more slowly.

Inspect skin regularly, particularly over

bony prominences. Gently massage any

reddened areas and provide aids such as

sheepskin pads as necessary.

Pressure points over bony prominences are most at risk

for decreased perfusion/ischemia. Circulatory

stimulation and padding help prevent skin breakdown

and decubitus development.

Begin active/passive ROM to all

extremities (including splinted) on

admission. Encourage exercises such as

quadriceps/gluteal exercise, squeezing

rubber ball, extension of fingers and

legs/feet.

Get patient up in chair as soon as vital signs

are stable, except following cerebral

hemorrhage.

Helps stabilize BP (restores vasomotor tone), promotes

maintenance of extremities in a functional position and

emptying of bladder/kidneys, reducing risk of urinary stones and

infections from stasis. Note: If stroke is not completed, activity

increases risk of additional bleed/infarction.

Pad chair seat with foam or water-filled

cushion, and assist patient to shift weight at

frequent intervals.

Prevents/reduces pressure on the coccyx/skin breakdown.

Set goals with patient/SO for participation

in activities/exercise and position changes.

Promotes sense of expectation of progress/improvement, and

provides some sense of control/independence.

Encourage patient to assist with movement

and exercises using unaffected extremity to

support/move weaker side.

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.

Provide egg-crate mattress, water bed,

flotation device, or specialized beds (e.g.,

kinetic), as indicated.

Promotes even weight distribution, decreasing pressure on bony

points and helping to prevent skin breakdown/decubitus

formation. Specialized beds help with positioning,enhance

circulation, and reduce venous stasis to decrease risk of tissue

injury and complications such as orthostatic pneumonia.

3. 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

Assess type/degree of dysfunction: e.g., patient does not seem to understand words or has

trouble speaking or making self understood.Differentiate aphasia from dysarthria;

Listen for errors in conversation and provide feedback;

Ask patient to follow simple commands (e.g., “Shut your eyes,” “Point to the door”);

repeat simple words/ sentences;

Point to objects and ask patient to name them;

Have patient produce simple sounds, e.g., “Sh,” “Cat”.

Ask patient to write name and/or a short sentence. If unable to write, have patient read a

short sentence.

Post notice at nurses’ station and patient’s

room about speech impairment. Provide

special call bell if necessary.

Allays anxiety related to inability to communicate and

fear that needs will not be met promptly. Call bell that is

activated by minimal pressure is useful when patient is

unable to use regular call system.

Provide alternative methods of

communication, e.g., writing or felt board,

pictures. Provide visual clues gestures,

pictures, “needs” list, demonstration).

Provides for communication of needs/desires based on

individual situation/underlying deficit.

Anticipate and provide for patient’s

needs.

Helpful in decreasing frustration when dependent on

others and unable to communication desires.

Talk directly to patient, speaking slowly

and distinctly. Use yes/no questions to

begin with, progressing in complexity as

patient responds.

Reduces confusion/anxiety at having to process and

respond to large amount of information at one time. As

retraining progresses, advancing complexity of

communication stimulates memory and further enhances

word/idea association.

Speak in normal tones and avoid talking

too fast. Give patient ample time to

respond. Talk without pressing for a

response.

Patient is not necessarily hearing impaired, and raising

voice may irritate or anger patient. Forcing responses can

result in frustration and may cause patient to resort to

“automatic” speech, e.g., garbled speech, obscenities.

Encourage SO/visitors to persist in efforts

to communicate with patient, e.g., reading

mail, discussing family happenings even if

patient is unable to respond appropriately.

It is important for family members to continue talking to

patient to reduce patient’s isolation, promote

establishment of effective communication, and maintain

sense of connectedness with family.

Discuss familiar topics, e.g., job, family,

hobbies.

Promotes meaningful conversation and provides

opportunity to practice skills.

4. 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

Review pathology of individual condition.

Awareness of type/area of involvement aids in

assessing for/anticipating specific deficits and

planning care.

Observe behavioral responses, e.g., hostility,

crying, inappropriate affect, agitation,

hallucination.

Individual responses are variable, but

commonalities such as emotional lability, lowered

frustration threshold, apathy, and impulsiveness

may complicate care.

Eliminate extraneous noise/stimuli as

necessary.

Reduces anxiety and exaggerated emotional

responses/confusion associated with sensory

overload.

Speak in calm, quiet voice, using short

sentences. Maintain eye contact.

Patient may have limited attention span or

problems with comprehension. These measures can

help patient attend to communication.

Ascertain/validate patient’s perceptions.

Reorient patient frequently to environment,

staff, procedures.

Assists patient to identify inconsistencies in

reception and integration of stimuli and may reduce

perceptual distortion of reality.

Evaluate for visual deficits. Note loss of visual

field, changes in depth perception

(horizontal/vertical planes), presence of diplopia

(double vision).

Presence of visual disorders can negatively affect

patient’s ability to perceive environment and

relearn motor skills and increases risk of

accident/injury.

Approach patient from visually intact side.

Leave light on; position objects to take

advantage of intact visual fields. Patch affected

eye if indicated.

Provides for recognition of the presence of

persons/objects; may help with depth perception

problems; prevents patient from being startled.

Patching may decrease the sensory confusion of

double vision.

Assess sensory awareness, e.g., differentiation

of hot/cold, dull/sharp; position of body

parts/muscle, joint sense.

Diminished sensory awareness and impairment of

kinesthetic sense negatively affects

balance/positioning and appropriateness of

movement, which interferes with ambulation,

increasing risk of trauma.

Stimulate sense of touch; e.g., give patient

objects to touch, grasp. Have patient practice

touching walls/other boundaries.

Aids in retraining sensory pathways to integrate

reception and interpretation of stimuli. Helps

patient orient self spatially and strengthens use of

affected side.

Protect from temperature extremes; assess

environment for hazards. Recommend testing

warm water with unaffected hand.

Promotes patient safety, reducing risk of injury.

Note inattention to body parts, segments of Presence of agnosia (loss of comprehension of

environment; lack of recognition of familiar

objects/persons.

auditory, visual, or other sensations, although

sensory sphere is intact) may lead to/result in

unilateral neglect, inability to recognize

environmental cues/meaning of commonplace

objects, considerable self-care deficits, and

disorientation or bizarre behavior.

Encourage patient to watch feet when

appropriate and consciously position body parts.

Make patient aware of all neglected body parts,

e.g., sensory stimulation to affected side,

exercises that bring affected side across midline,

reminding person to dress/care for affected

(“blind”) side.

Use of visual and tactile stimuli assists in

reintegration of affected side and allows patient to

experience forgotten sensations of normal

movement patterns.

5. 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

Assess extent of altered perception and

related degree of disability. Determine

Functional Independence Measure score.

Determination of individual factors aids in

developing plan of care/choice of interventions and

discharge expectations.

Identify meaning of the

loss/dysfunction/change to patient. Note

ability to understand events, provide realistic

appraisal of situation.

Independence/ability is highly valued in American

society but is not as significant in some other cultures.

Some patients accept and manage altered function

effectively with little adjustment, whereas others have

considerable difficulty recognizing and adjusting to

deficits. In order to provide meaningful support and

appropriate problem-solving, healthcare providers

need to understand the meaning of the

stroke/limitations to patient.

Determine outside stressors, e.g., family,

work, social, future nursing/healthcare needs.

Helps identify specific needs, provides opportunity to

offer information/support and begin problem-solving.

Consideration of social factors, in addition to

functional status, is important in determining

appropriate discharge destination.

Encourage patient to express feelings,

including hostility or anger, denial,

depression, sense of disconnectedness.

Demonstrates acceptance of/assists patient in

recognizing and beginning to deal with these feelings.

Note whether patient refers to affected side

as “it” or denies affected side and says it is

“dead.”

Suggests rejection of body part/negative feelings

about body image and abilities, indicating need for

intervention and emotional support.

Acknowledge statement of feelings about

betrayal of body; remain matter-of-fact about

reality that patient can still use unaffected

side and learn to control affected side. Use

words (e.g., weak, affected, right-left) that

incorporate that side as part of the whole

body.

Helps patient see that the nurse accepts both sides as

part of the whole individual. Allows patient to feel

hopeful and begin to accept current situation.

Identify previous methods of dealing with

life problems. Determine presence/quality of

support systems.

Provides opportunity to use behaviors previously

effective, build on past successes, and mobilize

resources.

Emphasize small gains either in recovery of

function or independence.

Consolidates gains, helps reduce feelings of anger

and helplessness, and conveys sense of progress.

Support behaviors/efforts such as increased

interest/participation in rehabilitation

activities.

Suggest possible adaptation to changes and

understanding about own role in future lifestyle.

Monitor for sleep disturbance, increased

difficulty concentrating, statements of

May indicate onset of depression (common after

effect of stroke), which may require further evaluation

inability to cope, lethargy, withdrawal. and intervention.

Refer for neuropsychological evaluation

and/or counseling if indicated.

May facilitate adaptation to role changes that are

necessary for a sense of feeling/being a productive

person. Note: Depression is common in 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 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

Assess abilities and level of deficit (0–4 scale) for

performing ADLs.

Aids in anticipating/planning for meeting

individual needs.

Avoid doing things for patient that patient can do

for self, but provide assistance as necessary.

These patients may become fearful and

dependent, and although assistance is helpful in

preventing frustration, it is important for patient to

do as much as possible for self to maintain self-

esteem and promote recovery.

Be aware of impulsive behavior/actions

suggestive of impaired judgment.

May indicate need for additional interventions

and supervision to promote patient safety.

Maintain a supportive, firm attitude. Allow

patient sufficient time to accomplish tasks.

Patients need empathy and to know caregivers

will be consistent in their assistance.

Provide positive feedback for efforts and

accomplishments.

Enhances sense of self-worth, promotes

independence, and encourages patient to continue

endeavors.

Create plan for visual deficits that are present,

e.g.:Place food and utensils on the tray related to

patient’s unaffected side;Situate the bed so that

patient’s unaffected side is facing the room with

the affected side to the wall;Position furniture

against wall/out of travel path.

Patient will be able to see to eat the food.Will be

able to see when getting in/out of bed and observe

anyone who comes into the room.Provides for

safety when patient is able to move around the

room, reducing risk of tripping/falling over

furniture.

Provide self-help devices, e.g., button/zipper

hook, knife-fork combinations, long-handled

brushes, extensions for picking things up from

floor; toilet riser, leg bag for catheter; shower

chair. Assist and encourage good grooming and

makeup habits.

Enables patient to manage for self, enhancing

independence and self-esteem; reduces reliance

on others for meeting own needs; and enables

patient to be more socially active.

Encourage SO to allow patient to do as much as

possible for self.

Reestablishes sense of independence and fosters

self-worth and enhances rehabilitation

process. Note: This may be very difficult and

frustrating for the SO/caregiver, depending on

degree of disability and time required for patient

to complete activity.

Assess patient’s ability to communicate the need

to void and/or ability to use urinal, bedpan. Take

patient to the bathroom at frequent/periodic

intervals for voiding if appropriate.

Patient may have neurogenic bladder, be

inattentive, or be unable to communicate needs in

acute recovery phase, but usually is able to regain

independent control of this function as recovery

progresses.

Identify previous bowel habits and reestablish

normal regimen. Increase bulk in diet; encourage

fluid intake, increased activity.

Assists in development of retraining program

(independence) and aids in preventing

constipation and impaction (long-term effects).

7. Risk for Impaired Swallowing

Risk factors may include

Neuromuscular/perceptual impairment

Review individual pathology/ability to swallow, noting extent of paralysis; clarity of

speech; facial, tongue involvement; ability to protect airway/episodes of coughing or choking;

presence of adventitious breath sounds; amount/character of oral secretions. Weigh periodically

as indicated.

Have suction equipment available at bedside,

especially during early feeding efforts.

Timely intervention may limit

amount/untoward effect of aspiration.

Promote effective swallowing, e.g.:Schedule activities/medications to provide a

minimum of 30 min rest before eating;Provide pleasant environment free of distractions (e.g.,

TV);Assist patient with head control/support, and position based on specific dysfunction;Place

patient in upright position during/after feeding as appropriate;

Provide oral care based on individual need prior to meal;

Season food with herbs, spices, lemon juice, etc. according to patient’s preference, within

dietary restrictions;

Serve foods at customary temperature and water always chilled;

Stimulate lips to close or manually open mouth by light pressure on lips/under chin, if needed;

Place food of appropriate consistency in unaffected side of mouth;

Touch parts of the cheek with tongue blade/apply ice to weak tongue;

Feed slowly, allowing 30–45 min for meals;

Offer solid foods and liquids at different times

Limit/avoid use of drinking straw for liquids;

Encourage SO to bring favorite foods.

Maintain upright position for 45–60 min

after eating.

Helps patient manage oral secretions and reduces risk of

regurgitation.

Maintain accurate I&O; record calorie

count.

If swallowing efforts are not sufficient to meet

fluid/nutrition needs, alternative methods of feeding must

be pursued.

Encourage participation in

exercise/activity program.

May increase release of endorphins in the brain,

promoting a sense of general well-being and increasing

appetite.

Administer IV fluids and/or tube

feedings

May be necessary for fluid replacement and nutrition if

patient is unable to take anything orally.

Coordinate multidisciplinary approach to

develop treatment plan that meets

individual needs.

Inclusion of dietitian, speech and occupational therapists

can increase effectiveness of long-term plan and

significantly reduce risk of silent aspiration.

8. 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

Evaluate type/degree of sensory-perceptual

involvement.

Deficits affect the choice of teaching methods and

content/complexity of instruction.

Include SO/family in discussions and teaching. These individuals will be providing support/care

and have great impact on patient’s quality of life.

Discuss specific pathology and individual

potentials.

Aids in establishing realistic expectations and

promotes understanding of current situation and

needs.

Identify signs/symptoms requiring further

follow-up, e.g., changes/decline in visual, motor,

sensory functions; alteration in mentation or

behavioral responses; severe headache.

Prompt evaluation and intervention reduces risk of

complications/further loss of function.

Review current restrictions/limitations and

discuss planned/potential resumption of

activities (including sexual relations).

Promotes understanding, provides hope for future,

and creates expectation of resumption of more

“normal” life.

Review/reinforce current therapeutic regimen,

including use of medications to control

hypertension, hypercholesterolemia, diabetes, as

indicated; aspirin or similar-acting drugs, e.g.,

ticlopidine (Ticlid), warfarin sodium

(Coumadin). Identify ways of continuing

program after discharge.

Recommended activities, limitations, and

medication/therapy needs are established on the

basis of a coordinated interdisciplinary approach.

Follow-through is essential to progression of

recovery/prevention of complications. Note: Long-

term anticoagulation may be beneficial for patients

older than 45 years of age who are prone to clot

formation; however, use of these drugs is not

effective for CVA resulting from vascular

aneurysm/vessel rupture.

Provide written instructions and schedules for

activity, medication, important facts.

Provides visual reinforcement and reference

source after discharge.

Encourage patient to refer to lists/written

communications or notes instead of depending

on memory.

Provides aids to support memory and promotes

improvement in cognitive skills.

Discuss plans for meeting self-care needs. Varying levels of assistance may be required/need

to be planned for based on individual situation.

Refer to discharge planner/home care

supervisor, visiting nurse.

Home environment may require evaluation and

modifications to meet individual needs.

Suggest patient reduce/limit environmental

stimuli, especially during cognitive activities.

Multiple/concomitant stimuli may aggravate

confusion and impair mental abilities.

Recommend patient seek assistance in problem-

solving process and validate decisions, as

indicated.

Some patients (especially those with right CVA)

may display impaired judgment and impulsive

behavior, compromising ability to make sound

decisions.

Identify individual risk factors (e.g.,

hypertension, cardiac dysrhythmias, obesity,

smoking, heavy alcohol use, atherosclerosis,

poor control of diabetes, use of oral

contraceptives) and discuss necessary lifestyle

changes.

Promotes general well-being and may reduce risk

of recurrence. Note: Obesity in women has been

found to have a high correlation with ischemic

stroke.

Review importance of balanced diet, low in

cholesterol and sodium if indicated. Discuss role

of vitamins and other supplements.

Improves general health and well-being and

provides energy for life activities.

Refer to/reinforce importance of follow-up care

by rehabilitation team, e.g.,

physical/occupational/speech/ vocational

therapists.

Diligent work may eventually overcome/minimize

residual deficits.

Other Nursing Diagnoses

1. Injury, risk for—general weakness, visual deficits, balancing difficulties, reduced large/small

muscle or hand-eye coordination, cognitive impairment.

2. Nutrition: imbalanced, less than body requirements—inability to prepare/ingest food, cognitive

limitations, limited financial resources.

3. Self-care deficit—decreased strength/endurance, perceptual/cognitive impairment,

neuromuscular impairment, muscular pain, depression.

4. Home Maintenance, impaired—individual physical limitations, inadequate support systems,

insufficient finances, unfamiliarity with neighborhood resources.

5. Self-Esteem, situational low—cognitive/perceptual impairment, perceived loss of control in

some aspect of life, loss of independent functioning.

6. Caregiver Role Strain, risk for—severity of illness/deficits of care receiver, duration of

caregiving required, complexity/ amount of caregiving task, caregiver isolation/lack of respite.