The document discusses the nursing process applied in stroke management, outlining its definition, development, and key components such as assessment, diagnosis, planning, implementation, and evaluation. It emphasizes the importance of evidence-based practice and critical thinking in patient care, alongside describing common nursing diagnoses associated with stroke patients. Additionally, it presents a case scenario illustrating the nursing process in action for a stroke patient.

1. NURSING PROCESS APPLICATION IN STROKE
INCLUDING SOME BASICS.
MRS.WINCY.C
PROFESSOR.

2. The American Nurses Association (ANA) defines the nursing process
as “the essential core of practice for the registered nurse to deliver
holistic, patient-focused care.
Or
Defined as a systematic approach to care, using the fundamental principles of
critical thinking, client-centered approaches to treatment, goal-oriented tasks,
evidence-based practice (EBP) recommendations, and nursing intuition.
WHAT IS NURSING PROCESS IN SIMPLE
WORDS?

3. WHAT IS NURSING PROCESS IN SIMPLE
WORDS?
ASSESS PATIENTS
PLAN
PROVIDE PATIENT CARE
AND
EVALUATE THE PATIENT’S
RESPONSE TO CARE.
The nursing process is a series of steps nurses take to
It is considered the
framework upon
which all nursing care
is based.

4. WHEN WAS THE NURSING PROCESS
DEVELOPED?
Lydia
Hall.
Ms.
Hall
The earliest version of the
nursing process was
introduced in 1955 by Lydia
Hall.
Ms. Hall identified three
steps of the nursing process:
observation,
administration of care, and
validation.
Dorothy
Johnson
Dorothy Johnson, in 1959,
described nursing
as "fostering the behavioral
functioning of the client.”
Ms. Johnson’s version of the
nursing process included the
three steps:
Assessment,
Decision, and
Nursing action.
Jean
Orlando-Pelletier
Finally, in 1961, Ida Jean
Orlando-Pelletier introduced
the version of the nursing
process known to nurses
today with five steps:
Assessment,
Diagnosis,
Planning,
Implementation, and
Evaluation.

5. To establish a
standard of
care
Protects
nurses
against
potential legal
problems
Establishes
plans to meet
patient needs
Guides
nurses in the
delivery of
high-quality
evidence-
based care
Promotes a
systematic
approach to
patient care
that all
members of
the nursing
team can
follow.
WHAT IS THE PURPOSE OF THE NURSING
PROCESS?

6. WHAT ARE THE IMPORTANT
STEPS/COMPONENTS OF
NURSING PROCESS
DEVELOPED?

7. 1.1. Assessment: This phase
involves collecting data about
the patient’s health status,
including physical, emotional,
and social aspects.
1.2. Diagnosis: In this phase, the
nurse identifies the patient’s health
problems based on the data
collected in the assessment phase.
1.3. Nursing goal. In the early
planning phase the nurse
formulates specific goals and desired
outcomes that will directly impact
patient care2. It is essential that the
goals the nurse sets are specific,
measurable, meaningful, achievable,
and action-oriented
4. Planning: The nurse
develops a plan of care that
outlines the interventions
required to address the
patient’s health problems on the
base of fixed nursing goal with
an appropriate rationale /reason
5. Rationale : It provides a critical thinking
statement that explains the underlying
reasoning for nurses’ interventions. Nursing
rationales are individualized and based on
scientific evidence, clinical judgment, and the
patient’s unique needs.
1.6. Implementation: The
nurse carries out the
interventions outlined in the
plan of care and document
them with date and time .
1.7. Evaluation: The nurse
evaluates the effectiveness of
the interventions and the
patient’s response to care in
reference to nursing goal.
6.8. Documentation: The
nurse documents the
patient’s health status, the
interventions provided, and
the patient’s response to
care.
1.9. Reassessment: The nurse
reassesses the patient’s health status
to determine if the interventions were
effective and if any changes to the
plan of care are required.
STEPS/PHASES/
COMPONENTS OF
NURSING PROCESS.

8. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG
INTERVENTION
RATIONAL IMPLIMENTATION
Do and document
EVALUATION
Ask yourself:
what data is
collected and
why do I think
this as a
problem?
Gathering the
supportrive
data .
Subjective
Data
(symptom)
1. History
Objective
Data (sign)
Verifying previous
documents
• Dx-diagnosis
• Sx-symptoms
• Rx-prescription
Physical
examination
Neurological
examination
Confirming with
the patient party
(with a double
check)
Ask yourself: “What is the
problem?”
Clinical judgement/problem
statement written by the nurse.
PES FORMAT
PROBLEM/Diagnostic label-
Ineffective cerebral tissue perfusion .
ETIOLOGY/related or risk
factors – hemorrhage
(Heamorrhagic stroke) or clot in a
cerebral vessel (Ischemic stroke) .
SIGN AND SYMPTOMS/defining
characteristics - right-sided
weakness, facial asymmetry, and
difficulty speaking.
PARTS OF A DIAGNOSTIC
LABEL
usually has two parts:
Ask: what the nurse hopes to
achieve by implementing the
nursing interventions derived from
the client’s nursing diagnoses?
Goals and expected outcomes must
be measurable and client-centered.
Goals can be short-term or long-
term.
Short-term goal:
It is a statement distinguishing a
shift in behavior that can be
completed immediately, usually
within a few hours or days.
Long-term goal:
Indicates an objective to be
completed over a longer period,
usually over weeks or months
Frame a statement of goal with the
client will maintain or
manage/identify etc
According to Hamilton and Price
(2013), goals should be SMART.
SMART goals analysis strategy
stands for – Specific, Measurable,
Attainable, Realistic, and Time-
Bound goals.
Ask: How to manage the
problem?
STEPS:
• Setting priorities
• Establishing goals
• Selecting nursing
interventions
• Documenting the
plan of care
METHOD OF
DOCUMENTING THE
NURSING
INTERVENTIONS.
Written under THREE
division
1.
Observation/Diagnostic
plans
2. Task/ Treatment
oriented plans
3. teaching/educational
plans
Be specific in planning
and thorough
Revise according to the
evaluation report
everyday.
Ask: why
should I select
this nursing
intervention?
It provides a
critical thinking
statement that
explains the
underlying
reasoning for
nurses’
interventions.
Ex:
Monitoring the
vital signs
enables the
nurse to plan
further specific
nursing
intervention
Or
Pain assessment
give an evidence
for the severity
of pain 8/10
Ask yourself: what
will I document ?
Putting the plan
into action
This phase
includes not only
doing but also
documenting the
provided nursing
care with date and
time.
METHOD OF
DOCUMENTING
THE
NURSING
Iimplimentations
/actions .
Written under
THREE division
1.
Observation/Diagno
stic plans
2. Task/ Treatment
oriented plans
3.
teaching/education
al plans
Criteria:
• Narrative note
• Not the
restatements of
your plan in past
tense
• Doesnot need to
address every plan
• Donot number or
Ask yourself:
Did the plan
work/ did I
accomplish my
goal?
POSSIBLE OUTCOMES :
There are three
possible
outcomes,
•Met
•Ongoing
•Not Met
The possible
patient
outcomes are
generally
explained under
three terms:
1.the patient’s
condition
improved,
2.the patient’s
condition
stabilized, and
3. the patient’s
condition
worsened.
QUALIFIER
Deficient
FOCUS OF THE
DIAGNOSIS.
Fluid volume
Imbalanced
Nutrition: Less Than Body
Requirements
Impaired Gas Exchange
Ineffective Tissue Perfusion
Risk for Injury

9. Nursing Diagnosis for Care Plans
This section is the list or database of the
common NANDA nursing diagnosis
examples
DIAGNOSTIC LABEL
Activity Intolerance
•Acute Pain
•Anxiety
•Chronic Pain
•Constipation
•Decreased Cardiac Output
•Deficient Fluid Volume
•Deficient Knowledge
•Diarrhea
•Excess Fluid Volume
•Fatigue
•Fear
•Grieving
•Hopelessness
•Hyperthermia
•Hypothermia
•Imbalanced Nutrition: Less Than Body
Requirements
•Impaired Gas Exchange
•Impaired Tissue (Skin) Integrity
•Impaired Urinary Elimination
•Ineffective Airway Clearance
•Ineffective Breathing Pattern
•Ineffective Tissue Perfusion
•Risk for Falls
•Risk for Impaired Skin Integrity
•Risk for Infection
•Risk for Injury
•Risk for Unstable Blood Glucose Level

10. • Patient problem present
during A nursing assessment
is known as A problem-
focused diagnosis
Problem-focused
Nursing Diagnosis
• Risk factors require
intervention from the nurse
and healthcare team prior
to A real problem
developing
Risk Nursing
Diagnosis
• Improve the overall well-
being of an individual, family,
or community
Health Promotion
Nursing Diagnosis
• A cluster/group of nursing
diagnoses that occur in a pattern
or can all be addressed through
the same or similar nursing
interventions
Syndrome
Nursing
Diagnosis
• A possible diagnosis is a statement about
a health problem that the client might
have now, but the nurse doesn’t yet
have enough information to make an
actual diagnosis.
• An example of a possible diagnosis
is: Possible fluid volume deficit in case of
frequent vomiting for three days .
Possible
Nursing
Diagnosis
TYPES OF NURSING DIAGNOSIS
There are 5 types of nursing diagnoses.

17. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG
INTERVENTION
RATIONAL IMPLIMENTATION
Do and document
EVALUATION
Ask yourself:
what data is
collected and
why do I think
this as a
problem?
Gathering the
supportrive
data .
Subjective
Data
(symptom)
1. History
Objective
Data (sign)
Verifying previous
documents
• Dx-diagnosis
• Sx-symptoms
• Rx-prescription
Physical
examination
Neurological
examination
Confirming with
the patient party
(with a double
check)
Ask yourself: “What is the
problem?”
Clinical judgement/problem
statement written by the nurse.
PES FORMAT
PROBLEM/Diagnostic label-
Ineffective cerebral tissue perfusion .
ETIOLOGY/related or risk
factors – hemorrhage
(Heamorrhagic stroke) or clot in a
cerebral vessel (Ischemic stroke) .
SIGN AND SYMPTOMS/defining
characteristics - right-sided
weakness, facial asymmetry, and
difficulty speaking.
PARTS OF A DIAGNOSTIC
LABEL
usually has two parts:
Ask: what the nurse hopes to
achieve by implementing the
nursing interventions derived from
the client’s nursing diagnoses?
Goals and expected outcomes must
be measurable and client-centered.
Goals can be short-term or long-
term.
Short-term goal:
It is a statement distinguishing a
shift in behavior that can be
completed immediately, usually
within a few hours or days.
Long-term goal:
Indicates an objective to be
completed over a longer period,
usually over weeks or months
Frame a statement of goal with the
client will maintain or
manage/identify etc
According to Hamilton and Price
(2013), goals should be SMART.
SMART goals analysis strategy
stands for – Specific, Measurable,
Attainable, Realistic, and Time-
Bound goals.
Ask: How to manage the
problem?
STEPS:
• Setting priorities
• Establishing goals
• Selecting nursing
interventions
• Documenting the
plan of care
METHOD OF
DOCUMENTING THE
NURSING
INTERVENTIONS.
Written under THREE
division
1.
Observation/Diagnostic
plans
2. Task/ Treatment
oriented plans
3. teaching/educational
plans
Be specific in planning
and thorough
Revise according to the
evaluation report
everyday.
Ask: why
should I select
this nursing
intervention?
It provides a
critical thinking
statement that
explains the
underlying
reasoning for
nurses’
interventions.
Ex:
Monitoring the
vital signs
enables the
nurse to plan
further specific
nursing
intervention
Or
Pain assessment
give an evidence
for the severity
of pain 8/10
Ask yourself: what
will I document ?
Putting the plan
into action
This phase
includes not only
doing but also
documenting the
provided nursing
care with date and
time.
METHOD OF
DOCUMENTING
THE
NURSING
Iimplimentations
/actions .
Written under
THREE division
1.
Observation/Diagno
stic plans
2. Task/ Treatment
oriented plans
3.
teaching/education
al plans
Criteria:
• Narrative note
• Not the
restatements of
your plan in past
tense
• Doesnot need to
address every plan
• Donot number or
Ask yourself:
Did the plan
work/ did I
accomplish my
goal?
POSSIBLE OUTCOMES :
There are three
possible
outcomes,
•Met
•Ongoing
•Not Met
The possible
patient
outcomes are
generally
explained under
three terms:
1.the patient’s
condition
improved,
2.the patient’s
condition
stabilized, and
3. the patient’s
condition
worsened.
QUALIFIER
Deficient
FOCUS OF THE
DIAGNOSIS.
Fluid volume
Imbalanced
Nutrition: Less Than Body
Requirements
Impaired Gas Exchange
Ineffective Tissue Perfusion
Risk for Injury

18. Dx-diagnosis
Sx-symptoms
Rx-prescription

19. Cerebrovascul
ar accident
(CVA), also
known as stroke,
acute ischemic
stroke, cerebral
infarction, or brain
attack.
Definition:
It is the sudden
impairment of
cerebral
circulation in one
or
more blood vessel
s supplying the
brain caused by
hemorrhage from
a tear in the
vessel wall or
impairs cerebral
circulation by
partial or
complete
occlusion of the
vessel lumen .
Strokes can be
classified into 2 main
categories:
•Ischemic strokes. These are
strokes caused by blockage
of an artery (or, in rare
instances, a vein). About 87%
of all strokes are ischemic.
•Hemorrhagic stroke. These
are strokes caused by
bleeding. About 13% of all
strokes are hemorrhagic.
2 main categories,
Ischemic strokes :
•Thrombotic strokes. These
are caused by a blood clot
that develops in the blood
vessels inside the brain.
•Embolic strokes. These are
caused by a blood clot or
plaque debris that develops
elsewhere in the body and
then travels to one of the
blood vessels in the brain
through the bloodstream.
2 main categories,
Hemorrhagic strokes”
Intracerebral hemorrhage.
Bleeding is from the blood
vessels within the brain.
•Subarachnoid hemorrhage.
• Bleeding is in the
subarachnoid space (the
space between the brain and
the membranes that cover
the brain).
AN OVERVIEW OF STROKE …

20. T
Y
P
E
S

24. MRS. FLORENCE, 73-YEAR OLD FEMALE
WITH STROKE
CASE SCENARIO

25. CASE SCENARIO
• Mrs. Florence,73-year old female presents to the ED with complaints of right-sided weakness and
difficulty speaking. The patient’s son said he was having lunch with his mom when she began having
problems holding her fork and using her right arm. When he asked his mom what was wrong, she had
difficulty finding words and was unable to properly formulate sentences. The patient’s son also noticed
her face appeared asymmetrical.
• Upon assessment, the patient appears drowsy. She is unable to answer orientation questions and
engages in endless word-searching, repeating sentences such as – “you… the… the…” The patient is able
to obey commands on the left side, but can only minimally move her right arm and leg. She can smile
and raise her eyebrows, but her face is asymmetrical and the right side is less mobile than the left. Her
gaze is normal and partial hemianopia is noted in the right visual field. The patient’s blood work is
within normal limits. A CT scan of the head is performed, confirming the presence of cerebral infarction.
The patient is admitted to the hospital for a Cerebrovascular Accident (CVA/Stroke).

26. NATIONAL INSTITUTES OF HEALTH STROKE
SCALE(NIHSS)
RESULT SUMMARY:
• 10 points out of 42 in NIH Stroke
Scale
• IMPRESSION: Moderate Stroke

27. Dysarthria is a motor speech disorder in which the muscles used to
produce speech are damaged, paralyzed, or weak.
A comprehension and communication (reading, speaking, or writing) disorder resulting from
damage or injury to the specific area in the brain.

28. PROBLEM IDENTIFICATION
• Right-sided weakness and difficulty speaking.
• Repeating sentences such as – “you… the… the…”
• She is unable to answer orientation questions
• Engages in endless word-searching
• She had difficulty finding words and was unable to properly formulate sentences.
• Having problems holding her fork and using her right arm.
• Her face appeared asymmetrical.
• The patient appears drowsy.
• The patient is able to obey commands on the left side, but can only minimally move her right
arm and leg.
• She can smile and raise her eyebrows, but her face is asymmetrical and the right side is less
mobile than the left.
• Her gaze is normal and partial hemianopia is noted in the right visual field.
Aphasia and dysarthria

29. APPLICATION OF
NURSING PROCESS

30. • Ineffective Tissue Perfusion related to interruption of blood flow
to the brain secondary to a cerebrovascular accident (CVA) as
evidenced by neurological deficits, altered level of consciousness,
and/or abnormal diagnostic tests.
Ineffective Tissue Perfusion :
stroke patient experience neurological
deficits and altered level of consciousness
due to lack of blood supply to the brain
• Impaired Physical Mobility related to weakness or paralysis of
one or more extremities, alterations in gait or balance, and/or
decreased coordination secondary to a cerebrovascular accident
(CVA)
Impaired physical mobility:
stroke patient experiences difficulty in
moving or controlling their limbs. This can
be due to muscle weakness, paralysis, or
spasticity.
• Impaired Verbal Communication related to neurological damage,
cognitive impairment, and/or language deficits secondary to a
cerebrovascular accident (CVA) as evidenced by difficulty
speaking, slurred speech, aphasia, and/or altered level of
consciousness
Impaired verbal communication:
Stroke patients may have difficulty speaking,
understanding speech, or expressing
themselves.
ACTUAL PROBLEMS IN STROKE

31. Actual problems in stroke
• Impaired Urinary Elimination related to urinary retention or
urinary incontinence secondary to a cerebrovascular accident
(CVA) as evidenced by decreased urinary output, difficulty
initiating or stopping the urinary flow, and/or involuntary loss
of urine.
Impaired urine elimination:
Stroke patients may have difficulty
controlling their bladder or bowel
movements
• Disturbed Sleep Patterns related to physiological and
psychological changes secondary to a cerebrovascular
accident (CVA) as evidenced by difficulty falling asleep,
difficulty staying asleep, and/or excessive daytime
sleepiness
Disturbed sleep pattern:
Stroke patients may experience
changes in their sleep patterns due to
pain, anxiety, or medication side effects
• Disturbed Sensory Perception related to altered sensory
input secondary to a cerebrovascular accident (CVA) as
evidenced by changes in vision, hearing, taste, smell, or
touch
Disrupted sensory perception:
Stroke patients may experience
changes in their vision, hearing,
or touch sensation.
ACTUAL PROBLEMS IN STROKE

32. •Risk of Aspiration related to (CAN BE REPLACED BY AEB) impaired
swallowing, decreased level of consciousness, and/or altered gag
reflex secondary to a cerebrovascular accident (CVA) as evidenced by
coughing, choking, and/or difficulty swallowing
Risk of Aspiration:
Stroke patients may have difficulty
swallowing, which can lead to
aspiration pneumonia.
•Risk of Falls related to (CAN BE REPLACED BY AEB) impaired balance,
decreased mobility, and/or altered level of consciousness secondary to
a cerebrovascular accident (CVA) as evidenced by unsteady gait,
dizziness, and/or confusion
Risk of Falls:
Patients with stroke may be at risk
of falling due to impaired balance
or mobility.
•Risk of Impaired Skin Integrity related to (CAN BE REPLACED BY AEB)
decreased mobility, impaired sensation, and/or incontinence
secondary to a cerebrovascular accident (CVA) as evidenced by
pressure ulcers, skin tears, and/or skin breakdown
Risk of impaired skin Integrity:
Patients with stroke may be at risk of
developing pressure ulcers due to
immobility or poor nutrition.
POTENTIAL PROBLEMS IN STROKE

33. ASSESSMENT NURSING
DIAGNOSIS
NURSING
GOAL/OBJECTIVE
PLANNING/NSG
INTERVENTION
RATIONAL IMPLIMENTATION EVALUATION
Subjective Data:
The son of Mrs.
Florence says that,
“my mom has right-
sided weakness,
drowsiness and
difficulty speaking from
2pm ”.
Objective Data:
The patient has right-sided
weakness, alterd level of
consciousness(
drowsiness),facial
asymmetry, and difficulty
speaking.
CT scan confirms the
presence of a cerebral
infarction.
Total NIHSS score is 10/42
LOC (DROWSY) (1) and LOC
ON COMMAND(OBEYS ONE
COMMAND (1)
Ineffective Tissue
Perfusion related
to interruption of
blood flow to the
brain secondary to
a cerebrovascular
accident (CVA) as
evidenced by
neurological
deficits, altered
level of
consciousness(dro
wsy), and/or
abnormal
diagnostic(CT scan)
tests.
Short-term goal:
The client will
maintain the normal
cerebral tissue
perfusion including
Stable vital signs .
improved LOC,
cognition, and
motor and sensory
functions .with in 8
hours of nursing care
Long-term goal:
The patient will
show the
improvement in
the cerebral
tissue perfusion
including level of
consciousness
and ability to
obey the both
commands but
she will show
the readiness to
modify her
lifestyle within
few months .
DIAGNOSTIC/OBSERVATIONAL
INTERVENTIONS OR PLANS
Check hemodynamic studies. Monitor vital
signs, including blood pressure, heart rate,
respiratory rate, and oxygen saturation,
Check rapid changes or continued shifts in
mental status, Evaluate motor reaction to
simple commands, noting purposeful and non-
purposeful movement, Evaluate verbal
reaction, Monitor higher functions, as well as
speech, if the client is alert.
Monitor cerebral perfusion pressure (CPP) and
Measure the client’s ICP. Keep an eye on the
patient’s diagnostic tests results, such as CT
scans or MRIs, for changes in the size or location
of the stroke, Assess the patient’s response to
drugs and oxygen therapy, including changes in
blood pressure, oxygen saturation, and
neurological condition. and Document limb
movement and note right and left sides
individually.
Observing the
hemodynamics ,CPP,ICP
and neurological , sensory
impairment
communication ability
will provide a clear picture
to the nurse to plan and
implement further nursing
care to increase the
cerebral tissue perfusion in
the client.
On assessment the client’s vital signs are
as follows ;BP 172/90mmhg; Temp
98.3df; HR 118bts/m; RR 22brths/m;
O2 Sat 95%... CPP is 50 mmHg
(decreased ) and ICP is 20 MmHg
(increased) shows the ischemic injury,
Symptoms of a poor cerebral tissue
include loss of consciousness
(drowsiness) able to obey only one
command at a time ,sudden weakness in
the right side , face appeared
asymmetrical. appeared drowsy,
unable to communicate and partial
hemianopia in the right side are
found.
#1 CVA/Stroke Nursing Care Plan – Ineffective Tissue Perfusion

34. ASSESSMENT NURSING
DIAGNOSIS
NURSING
GOAL/OBJECTIVE
PLANNING/NSG
INTERVENTION
RATIONAL IMPLIMENTATION EVALUATION
TREATMENT /TASK
INTERVENTIONS OR PLANS
Positioning the patient in a way
that promotes blood flow to the
brain can help improve cerebral
perfusion, Elevate the head of the
bed to 30 degrees.Administer
oxygen therapy as ordered(10-
15L/min),Provide adequate oral
fluids to drink,Administer isotonic
saline without dextrose iv
fluids( 0.9% Normal Saline (0.9%
NaCl) ,Encourage mobility and
ambulation as appropriate
Administer medications as
ordered, such as antiplatelet
agents (aspirin, 50-325 mg /day ),
thrombolytics( alteplase, 0.9
mg/kg ) as per order.
Supplemental oxygen,
elevation of the head end
of the bed, increasing the
physical mobility
thrombolytics and
antiplatelet drugs will
reduce the blood clotting
and improve the cerebral
tissue perfusion.
The client is placed in a
comfortable position with head
elevation at less than 30 degree
,oxygen is administered through a
non breather mask about 12l/m,
iv fluid 0.9% NaCl is infused and
thrombolytic agent is administered
intravenously 100mg/day as per
doctor’s order.
#1 CVA/Stroke Nursing Care Plan – Ineffective Tissue Perfusion

35. ASSESSMENT NURSING
DIAGNOSIS
NURSING
GOAL/OBJECTIV
E
PLANNING/NSG
INTERVENTION
RATIONAL IMPLIMENTAT
ION
EVALUATION
. Teaching interventions or
plans
Teach the client to increase the
rate and depth of breathing,
Educate to maintain adequate
hydration is important for
improving cerebral perfusion,
Motivate the client to increase
the physical mobility. Counsel the
client to do life style
modifications, and teach the
client to avoid excess stress
Teaching the client
regarding breathing
exercises, physical
activity ,hydration
and stress free life
style will enable the
client to maintain
normal tissue
perfusion.
The client was
encouraged to
practice fast
breathing
technique
progressively, the
family members
took initiation to
frequently
hydrating the
patient with
some oral fluids
like water, juices,
etc. she started to
walk with
assistance in the
right side and
shown readiness
to modify the life
style including
water intake,
physical activity,
avoid processed
foods and stress
adaptive
techniques.
1.Short term goal
Goal is partially met
With in the 8 hours of patient care
the patient demonstrated an
improvement in LOC like
drowsiness and obeying both the
commands correctly. right-sided
weakness and able to verbally
communicate to some extend than
the earlier state.
NIHS score for language (aphasia ) is
still remains 1 but dysarthria is
improved from 1 to 0.
Total NIHS score is 9/42
2. Long term goal
Goal is partially met
The patient shown sign of
improvement in the level of
consciousness and ability to obey
the both commands but she
assured her readiness to maintain
normal tissue perfusion in the future
with her medications and lifestyle
#1 CVA/Stroke Nursing Care Plan – Ineffective Tissue Perfusion

36. ASSESSMENT NURSING
DIAGNOSIS
NURSING
GOAL/OBJECTIVE
PLANNING/NSG
INTERVENTION
RATIONAL IMPLIMENTATION EVALUATION
Subjective Data:
The son of Mrs.
Florence says that,
“my mom has right-
sided weakness and
difficulty speaking
from 2pm ”.
Objective Data:
The patient has right-
sided weakness, facial
asymmetry, and
difficulty speaking.
CT scan confirms the
presence of a cerebral
infarction.
Total NIHSS score is
10/42
Mild to moderate
dysarthria(1) and mild
to moderate
aphasia(1)
Impaired verbal
communication
related to
hemorrhage
(Heamorrhagic
stroke) or clot in
a cerebral vessel
(Ischemic stroke)
as evidenced by
right-sided
weakness, facial
asymmetry, and
difficulty
speaking.
Short-term goal:
By the end of the
shift, the patient
will demonstrate
an improvement
in speaking ability
and demonstrate
equal bilateral
motor strength..
Long-term goal:
The patient will
return to baseline
and experience
no residual
neurological
dysfunction .
Diagnostic interventions or
plans
Perform physical and neurological
examination to identify the facial
asymmetry and muscular weakness
Assess higher functions, including
speech. Use the National Institutes
of Health Stroke Scale (NIHSS) for
assessing neurologic impairment
Assess the client for aphasia and
dysarthria and Differentiate and
check for fluency.
Point to objects and ask the client to
name them .
Ask the client to produce simple
sounds (“dog,” “meow,” “Shh”) to
check the articulation and Assess
the client for signs of depression.
Enables the nurse to
determine the exact cause
for the speech difficulty,
Changes in cognition and
speech content indicate
location and degree of
cerebral involvement and
may indicate deterioration or
increased ICP. Also helps to
rule out depression due to
aphasia .
On assessment Mrs. Florence has
facial asymmetry, Right-sided
weakness and difficulty speaking,
unable to answer orientation
questions, engages in endless
word-searching, Repeating
sentences such as – “you… the…
the…”
The clients ability to speech is
clinically assessed by using National
Institutes of Health Stroke Scale
(NIHSS) .the result is Total NIHSS
score is 10/42. Mild to moderate
dysarthria(1) and mild to moderate
aphasia(1). On observation she
couldn't articulate and had fluency
issues and She was bit depressed on
being unable to communicate with her
family members .
#1 CVA/Stroke Nursing Care Plan – Impaired verbal communication

37. ASSESSMENT NURSING
DIAGNOSIS
NURSING
GOAL/OBJECTIVE
PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION EVALUATION
Treatment oriented interventions
Ask the client to write their name and a short
sentence. If unable to write, have the client read a
short sentence.
Write a notice at the nurses’ station and the client’s
room about speech impairment.
Talk directly to the client, speaking slowly and
distinctly.
Gain the client’s attention when speaking.
Phrase questions to be answered simply by yes or no.
Progress in complexity as the client responds.
Speak in normal tones and avoid talking too fast. Give
the client ample time to respond. Avoid pressing for a
response.
Use gestures or related photographs to enhance
comprehension.
Discuss familiar topics (e.g., weather, family, hobbies,
jobs).
Eliminate extraneous noise and stimuli as necessary.
Consult and Collaborate with a speech therapist and a
physiotherapist to improve the right sided weakness
and to improve the speech.
A comprehensive
multidisciplinary
plan with
meaningful
conversation, Noise
free environment
speech and physio
therapy will improve
the patient’s
communication
ability..
The client was encouraged and
motivated to improve her verbal
communication and encouraged
her to ventilate her emotions orally
and by gestures .
Used simple sentences and words
to repeat ,some pictures of fruits
animals to read she was able to do
moderately , frequently asked
some orientation questions on her
name,age,time,place it helped her
to enhance her ability to articulate.
Noise free environment helped her
so much to be calm and focus on
improving the vocabulary practice
without any frustrations .
Family members also actively
collaborated with the speech
therapist and physiotherapist to
increase the facial muscle strength.
#1 CVA/Stroke Nursing Care Plan – Ineffective cerebral tissue perfusion

38. ASSESSMEN
T
NURSING
DIAGNOSIS
NURSING
GOAL/OBJECTIVE
PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION EVALUATION
Teaching the client
Encourage significant others (SO) to
continue communicating with the client:
reading mail and discussing family
happenings even if the client cannot
respond appropriately.
Educate the family members need to
continue talking to clients to reduce the
client’s isolation, promote effective
communication, and maintain a sense of
connectedness with the family.
Teach techniques to improve speech by
Asking to talk slowly and say each word
clearly.
Encouraging them to speak in short
phrases.
If verbal communication is difficult, asking
the patient to write a message or draw a
picture.
Encouraging the family
members to help the
client to establish
interesting
conversation and
keeping the client
engaged by a family
members will help to
rid off the depression,
loneliness and
progressively improve
the ability to speak
fluently.
The family members and friends
played very vital role in keeping the
client emotionally warm, engaged
throughout, client also practiced the
techniques taught her to do .these
interventions helped the client to
regain her normal ability to
communicate .
1.Short term goal
Goal is partially met
By the end of the shift the patient
demonstrated an improvement in
right-sided weakness and able to
verbally communicate to some
extend than the earlier state.
NIHS score for language (aphasia )
is still remains 1 but dysarthria is
improved from 1 to 0.
Total NIHS score is 9/42
2. Long term goal
Goal is partially met
The patient shown some
evidence of improvement in her
verbal communication and she
will successfully continue
demonstrate further improvement
in aphasia and able to
communicate verbally without any
hindrance in the fluency and
articulation of words .
#1 CVA/Stroke Nursing Care Plan – Ineffective cerebral tissue perfusion