for educational purpose only..

1. 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.

2. 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)

3. 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,

4. 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

5. 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

6. 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 vaso-spasm, 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.

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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;

16. 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

17. 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.

18. 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.

19. 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.