Stroke Care Plans, Nursing Diagnosis and Interventions

Introduction

Stroke care plans are guidelines that provide direction on the type of nursing care  to de administered to a stroke patient. The main aim of a stroke care plan is to facilitate standardized, evidence-based and holistic care for a patient.

Stroke or Cerebrovascular accident (CVA), also known as cerebral infarction, brain attack, is any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels of the entire cerebrovascular system. Stroke is characterized by a sudden loss of cerebral perfusion or vasculature.

Impaired physical mobility and ineffective tissue perfusion are common nursing diagnoses that will discuss and provide stroke care plans for, among other stroke diagnoses.

Cerebrovascular Accident

Cerebrovascular Accident

This blog post will explain what stroke is, different types of stroke, diagnosis of stroke, and different stroke care plans. As you follow along, remember that our qualified writers are always ready to help in any of your nursing assignments. All you need to do is place an order with us!

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

What is Stroke or Cerebrovascular accident (CVA)?

Stroke/Cerebrovascular accident (CVA), also known as cerebral infarction, brain attack, is a functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels of the entire cerebrovascular system.

It is characterized by a sudden loss of cerebral perfusion or vasculature. Impairment of cerebral vessels may prevent blood circulation to the brain resulting in damage and death of cells, causing the stroke.

Types of Stroke

Main types of strokes:

  • Transient ischemic attack (TIA).
  • Ischemic stroke.
  • Hemorrhagic stroke.
  • Embolic stroke

 These types of strokes are further subdivided into embolic stroke, thrombotic stroke, intracerebral stroke, and subarachnoid stroke.

Ischemic Stroke

 The arteries that supply blood to the brain are narrowed or blocked during a stroke. It can also occur due to fracture of plaque fragments and blockage of blood vessels due to atherosclerosis. Thrombotic and valvular strokes are the two most common types of ischemic strokes.

When a blood clot forms in one of the arteries that supply blood to the brain, it causes a stroke. The clot travels through the bloodstream and settles, blocking blood flow. An embolic stroke occurs when a blood clot or other debris forms elsewhere in the body and travels to the brain.

Ischemic stroke is more common among the elderly, who are more likely to develop atherosclerosis. As a result, anti-atherosclerosis therapies that reduce the risk of atherosclerosis may help lessen their chances of having an ischemic stroke.

Embolic stroke

An embolic stroke is one of two forms of ischemic stroke. It occurs when a blood clot forms elsewhere in the body — generally the heart or arteries in the upper chest and neck — and travels to the brain through the bloodstream. A clot forms in the arteries of the brain, blocking blood flow and resulting in a stroke. A cardiac problem can cause an embolic stroke. A common type of abnormal heartbeat, atrial fibrillation, can cause blood clots to develop in the heart. These clots may dislodge and move via the bloodstream to the brain.

Transient ischemic attack (TIA)

This type of stroke occurs whenever blood flow to the brain is temporarily disrupted, a transient ischemic attack, also known as a TIA or ministroke, occurs. A blood clot usually causes a TIA. A TIA can be a symptom of a future stroke, so don’t disregard it.

Hemorrhagic stroke

When a cerebral artery ruptures or bleeds blood, a hemorrhagic stroke develops. Increased pressure in the skull and swelling of the brain is caused by blood from that artery, causing damage to brain cells and structures. Hemorrhagic strokes are divided into two categories: intracerebral and subarachnoid. When an artery bursts, the tissues around the brain flood with blood, resulting in a hemorrhagic stroke. A less common type of stroke is subarachnoid hemorrhagic stroke. It causes bleeding between the brain and its surrounding tissues.

This kind of stroke is caused by age-related alterations in the aligning cells of an artery supplying that portion of the brain, which are known as cerebral amyloid angiopathies.

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Stroke Signs and Symptoms

Stroke can manifest clinically in a variety of ways. To improve treatment outcomes, it is vital to seek medical attention as soon as possible. The Signs and Symptoms include:

  • Difficulty speaking and comprehending what others are saying – persons who have had a stroke may become confused, speak slurredly, and have trouble understanding what others are saying.
  •  Sudden paralysis of the face, arm, or leg – in persons with stroke, sudden onset of weakness, usually on one side of the body, is common.
  •  Vision problems in one or both eyes – vision alterations can occur due to a stroke. A person may have sudden double vision or vision loss.
  •  Headache – a person suffering from a stroke may experience a severe headache followed by vomiting, dizziness, or confusion.
  • Unsteady gait – a person’s coordination and ability to walk may be affected by weakness.

This nursing diagnosis is generally given to a victim of a cerebrovascular accident (CVA) who has lost physical mobility. This might make it difficult for the person to move around, dress oneself, use their hands for self-care duties like eating and toileting, and conduct other everyday tasks (ADLs).

Nursing Diagnosis for Stroke

Impaired physical mobility

Stroke patients may require assistance with ADLs (e.g., eating, dressing) and a decreased capacity to communicate requirements and self-care activities, making emotional and physical coping challenging.

Dealing Hurdles

This is another nursing diagnosis for cerebrovascular accident victims who often experience feelings of fear, anxiety, anger, and depression as a result of an altered physical appearance (e.g., paralysis), which can make a person feel as if there’s no point in trying because nothing will ever change how they feel about themselves from now on. Strokes have been related to mood and behavior changes, both of which can be difficult to manage.

Inability to care for oneself due to a lack of physical mobility

Depending on where the impairment occurs within the brain’s hemispheres, it may affect one side (hemiparesis) or both sides (bilateral paresis) of the body. This impairs the person’s ability to conduct ADLs and other everyday duties, such as dressing themselves and feeding themselves with utensils at mealtime activities.

The body may also suffer muscle spasms or contractions at this level. These are the factors that make treating this nursing diagnosis so challenging. In most circumstances, friends and family must work together to assist nurses in dealing with this situation.

Perfusion problems in the cerebral tissue

Increased intracranial pressure disrupts neurological function by reducing or preventing the appropriate transport of nutrients and oxygen to cells in that part of the brain. Due to a lack of these essential components, the interruption may induce cell damage or death.

When there is a reduction in blood flow to the brain or a stoppage in its delivery, cerebral tissue perfusion is compromised. The symptoms and problems of a stroke victim are determined by which part of the brain has been impacted by the lack of interruption of blood flow.

Risk of Disuse Syndrome

Stroke victims have a variety of bodily changes as a result of cerebrovascular injury. These include muscle atrophy, decreased range of motion, and postural instability, as well as the development of pressure sores as a result of incapacity or trouble moving around, all of which can lead to long-term disability.

Patients with this nursing diagnosis are also at risk for disuse syndrome, which occurs after they have been sedentary for an extended period of time without receiving any form of therapy. This is why they need to be monitored, and care plans created so that nurses can figure out how to best help people with this disease get back on track in some way.

Imbalance (e.g., dizziness)

Nurses must be aware of the potential for imbalances as a result of this diagnosis. Strokes frequently affect one side or area of their body, which can cause balance issues, particularly dizziness and vertigo, which makes them feel as if they’re spinning when they’re not. Because it’s so difficult for them to maintain a proper equilibrium level when coping with these challenges, they may lose consciousness or trip over something by accident.

The skills of nurses are vital here as well because there must be intervention before accidents occur while doing things such as washing or feeding themselves without sufficient supervision or aid owing to a lack of coordination when making motions combining both limbs (such as kicking a ball).

Uncoordinated motor function

A person’s coordination has been known to be affected by strokes. This is due to the damage that has occurred as a result of a lack of oxygen to their brain, which might lead to an irreversible path if adequate rehabilitation treatments are not accessible for people who require them.

Because it might lead to an inability or trouble completing particular types of movements, motor functioning is a crucial issue with this diagnosis.

The ability of nurses is critical in this situation because they will need to monitor these things and intervene before an injury occurs while attempting activities such as bathing and feeding themselves without proper supervision or assistance due to a lack of coordination when making movements involving both limbs.

Challenges in Eating

Nurses should be aware of any eating or drinking issues that come with this diagnosis, such as dysphagia (difficulty swallowing food or liquids), esophageal reflux, and the risk of aspiration pneumonia (excess fluid in the airway while trying to breathe through both nostrils and mouth-to-mouth respiration).

If a patient has this, they should be monitored because if it gets bad enough, they could develop aspiration pneumonia, which can lead to death due to infection in the lungs – and they might not even realize it until it’s too late because sometimes people don’t realize when things are happening orally (like breathing) versus an injury on another part of their body: intervention is needed before injuries happen.

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Stroke Care Plans
Stroke Care Plans

Risk of unilateral neglect

Nurses must be aware of the likelihood that a stroke survivor is in danger of neglect. Neglect occurs when one side or part of their body does not appear to exist in their mind. This can be caused by a variety of factors, including hemianopia (loss of visual field on one side) and hemineglect syndrome, in which they are unable to detect anything on the opposite side because it does not register at all.

Nurses’ ability to monitor these items is critical so that they can intervene before an injury occurs when doing activities such as washing or feeding themselves without sufficient supervision or assistance. Neglect is a common cause of harm in those who have had a cerebrovascular accident.

Disturbed sensory perception

A stroke victim may experience numbness in their limbs, vision problems, hearing and speech issues, and difficulty understanding what is written when reading. Patients who have had a stroke may also have difficulty perceiving sensations (e.g., touch). Any of the following can cause this:

  • Damage to nerves that convey impulses from the skin or muscles, preventing pain signals from being transmitted.
  • Changes in nerve cells, such as the ability to process touch sensations being lost.
  • On the one hand, there are disruptions in the language/speech parts of the brain, which can lead to difficulties understanding spoken words due to an inability to process auditory cues such as abrupt changes in sound frequency or volume level.

Inability to concentrate on one stimulus at a time.

For persons with this condition, a lack of concentration may be a concern. This is because it might cause an inability or difficulty with certain sorts of motions, which could be harmful if they are driving and need to make quick decisions and perform maneuvers like braking abruptly or steering unexpectedly (possibly without realizing the appropriate time frame).

Nurses’ ability to monitor these things and intervene before an injury happens while trying activities like bathing oneself, feeding themselves without sufficient supervision/help available owing to lack of coordination when making motions requiring both limbs (such as kicking a ball), etc.

Memory lapses

Memory issues, such as forgetting events, conversations, or duties, might be a side consequence of this diagnosis. Patients may find it challenging to recall when they need medication or to follow other steps in their care plan as a result of this (such as drinking fluids).

Nurses’ ability to monitor these things and intervene before injury occurs out there while trying activities like bathing themselves, feeding themselves without proper supervision/help being available due to lack of coordination when making movements involving both limbs (such as kicking a ball), etc.

Loss of meaning in life

It may be challenging for persons with this nursing diagnosis to find meaning in their lives, leading to feelings of depression or pessimism.

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

Other Diagnoses of Stroke

• Blood tests – to assess clotting capacity, blood sugar levels, and the possibility of infection.

• A CT scan of the brain can assist diagnose a stroke. It will produce comprehensive brain images that will reveal the existence of hemorrhage, ischemia, or tumors.

• An MRI scan is a type of brain imaging that can be used if a CT scan is inconclusive or if a more detailed image of the brain is required.

• Carotid scan – an ultrasound examination of the carotid artery to look for plaques in the arterial wall and assess blood flow to the brain.

• Echocardiogram – to check for blood clots in the heart that could cause ischemia in the brain’s blood arteries.

Stroke causes

Brain cells, like the rest of the body’s organs, require oxygen to survive. A stroke can be caused by anything that disrupts the blood supply to the brain. Strokes can be caused by anything that disrupts the blood supply to the brain.

The causes of stroke can be categorized as hemorrhagic or ischemic.

Hemorrhagic stroke occurs when a blood vessel in the brain rupture, enabling blood to pour through the brain, killing the cells that surround it. Here are some of the most common reasons for blood vessel rupture:

• Hypertension 

•Overuse of blood thinners or anticoagulants 

• Aneurysm 

• Trauma, such as a vehicle accident

• Protein deposits in the blood vessel wall, as in cerebral amyloid angiopathy 

• Aneurysm • Trauma such as a vehicle accident • Protein deposits in the blood vessel wall, such as in cases of cerebral amyloid angiopathy • Ischemic stroke leading to bleeding.

Ischemic stroke happens when a blood artery in the brain becomes severely constricted or occluded, resulting in a considerable reduction or complete loss of blood supply.

This is the most prevalent cause of stroke, accounting for around 85% of all instances.

A blood clot from elsewhere in the body becomes dislodged in one of the brain’s blood vessels, which is the most common cause.

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Treatment of Stroke

For ischemic Stroke:

1. Intravenous administration of medications to dissolve clots -treatments that dissolve clots will restore blood supply to the brain and prevent further harm. Intravenous administration of medicines allows for faster drug delivery to the site of need.

2. Endovascular operations in an emergency

• Direct administration of drugs to break clots in the brain – endovascular techniques allow medications to be delivered directly to the brain. A catheter is placed into the groin via an artery and threaded to the bladder.

• Using a stent retriever to remove the blood clot – a method to retrieve the clot can also be done using stent implantation. A catheter is implanted into the brain, and then a stent is placed into the tube to reach the clot’s location in the brain.

3. Carotid endarterectomy: This surgery includes removing plaque from the carotid artery. This surgery is risky, particularly for those who have heart problems.

4. Angioplasty and stents – angioplasty balloons and stents can be used to unblock a blocked blood artery.

Hemorrhagic Stroke (HS)

In hemorrhagic stroke, the goal of treatment is to stop the bleeding.

1. The following are emergency procedures:

  • Medications used to counteract the effects of blood thinners
  • Blood transfusion – to thicken the blood by increasing the volume of the blood
  • Blood pressure-lowering medications (antihypertensives).

2. Surgical intervention – in severe bleeding cases, surgical operations to remove the blood and repair blood vessels may be necessary.

3. Surgical clipping – in this technique, an aneurysm is clipped to prevent it from exploding or to control bleeding if it has already ruptured.

4. Endovascular embolization – a treatment in which coils are used to close a damaged blood artery.

5. Surgical AVM removal – only if the AVM is easily accessible in the brain is this surgery conducted.

6. Stereotactic radiosurgery uses highly targeted radiation to treat blood vessel malformations.

Stroke Care Plans

The nursing stroke care plan goals may include:

  1. Increase your mobility.
  2. Shoulder soreness is avoided.
  3. Self-care is achieved.
  4. Sensory and perceptual deprivation is alleviated.
  5. Aspiration prevention.
  6. Bowel and bladder continence.
  7. Improved thinking abilities.
  8. Achieving a form of communication.
  9. Maintaining the integrity of the skin.
  10. Enhance sexual function.
  11. Complications are not present.

Nursing Interventions Based on Stroke Care Plans

The patient’s recuperation is greatly influenced by nursing care. In summary, the following are some nursing interventions for stroke patients:

Positioning. Prevent contractures, reduce pressure, achieve appropriate body alignment, and avoid compressive neuropathies by assuming this position.

Avoid flexion. To prevent bending of the afflicted extremity, wear a splint at night.

Adduction should be avoided. A pillow in the axilla might be used to prevent adduction of the afflicted shoulder.

Edema should be avoided at all costs. To avoid edema and fibrosis, elevate the affected arm.

Full range of motion. Maintain joint mobility by allowing a full range of motion four or five times per day.

Prevent venous stasis by wearing compression stockings. Exercise can help avoid venous stasis, which can lead to thrombosis and pulmonary embolus in patients.

Re-establish equilibrium. Teach the patient to maintain balance when sitting, then standing, and finally walking as soon as standing balance is mastered.

Personal cleanliness is really important. Encourage the patient to participate in personal hygiene routines as soon as he or she is able to sit up.

Organize sensory issues. On the side where visual perception is intact, approach the patient with a reduced field of vision.

Make an appointment with a speech therapist. Consult a speech therapist to assess gag reflexes and help with other swallowing techniques.

Voiding pattern. Analyze the patient’s voiding pattern and recommend a urinal or a bedpan based on the patient’s voiding routine.

Maintain consistency in the activities of the patient. Maintain a constant timetable, routines, and repetitions; a written schedule, checklists, and audiotapes may aid memory and focus, and a communication board may be employed.

Inspect the patient’s skin. Examine the skin for symptoms of deterioration on a regular basis, focusing on bony areas and body parts that are dependent.

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Stroke Care Plans
nursing care plan for self care deficit related to stroke

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Stroke Prevention

Stroke can be avoided in a variety of methods, including:

Keeping a sedentary lifestyle to a minimum

Consuming a nutritious diet rich in fruits and vegetables

Avoiding the use of tobacco and recreational substances such as cocaine.

Maintaining normal blood pressure and cholesterol levels, avoiding high-risk activities, not drinking too much alcohol, eating foods that reduce the risk of stroke (such as whole grains and vegetables), exercising, maintaining a healthy weight, and not sleeping too much or too little can all help to prevent stroke.

Stress should be avoided because it can lead to a stroke.

Nurses should exercise caution when delivering drugs that have been shown to raise the risk of vascular events in this population, as they may trigger an adverse event (blood pressure medication like beta-blockers).

Summary

Stroke is any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels of the entire cerebrovascular system.

Transient ischemic attack (TIA), Ischemic stroke, Hemorrhagic stroke, and Embolic stroke are the main types of stroke.

Diagnosis of stroke involves using one of these methods; Blood tests, CT scan, MRI scan, Carotid scan, and Echocardiogram.

Improve mobility, achievement of self-care, prevention of aspiration, among others, are some of the care plans adopted by nursing for stroke patients.

Related FAQs

1. What is nursing care plan for self care deficit related to stroke?

The primary nursing care plan goals for patients with stroke depend on the phase of CVA the client is in. During the acute phase of CVA, efforts should focus on survival needs and prevent further complications.

2. What is a nursing care plan for stroke patients?

There a nursing care plan for stroke patients is applied to foster the restoration of affected cells. However, post-stroke treatment should not end after the person exits the hospital. The doctor always provides a care plan for a stroke patient at home. It is crucial to follow this set of instructions.

3. How to care for a stroke patient at home?

When going through a care plan for a stroke patient at home, one cannot miss even one day. Soon enough, the patient will already work out movements, the muscles will strengthen, and the energy level will rise. It is a long process that requires skill, patience, and expertise.

4. What are the goals of an 8+ stroke care plan?

Main article: 8+ Cerebrovascular Accident (Stroke) Nursing Care Plans. The major goals for the patient and family may include: Improve mobility. Avoidance of shoulder pain. Achievement of self-care. Relief of sensory and perceptual deprivation. Prevention of aspiration.

5. What is a healthy diet for stroke patients?

A healthy diet is the part of a nursing care plan for stroke patients that provides the recharge for a body that has gone through an immense amount of stress. Good food always helps regain powers and brings some joy along the tough road to recovery.

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Nursing Care Plans

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