Stroke Nursing Care Plan - Simple Nursing

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Pathophysiology
Nursing Assessment
Nursing Interventions
NCLEX Questions

Stroke Pathophysiology

A stroke is a sudden neurological event that occurs due to a disruption of blood flow to the brain, leading to inadequate perfusion. Two internal carotid arteries regulate blood flow to the brain in the front of the neck, and two vertebral arteries are located at the back of the neck.

An ischemic stroke occurs due to a lack of sufficient blood and oxygen supply to the brain, while a hemorrhagic stroke results from bleeding or leakage from blood vessels in the brain. Both types of stroke can lead to significant neurological damage and require prompt medical attention.

Around 10-15% of all strokes are classified as hemorrhagic strokes, which have a higher mortality rate than other types of stroke.¹ Hemorrhagic strokes occur when an internal injury or excessive pressure in the brain tissue causes blood vessels to rupture, releasing blood into the surrounding tissue.

This can result in toxic effects on the vascular system and potentially lead to infarction or tissue death.

Causes of Stroke

Stroke can occur due to two primary causes: a blocked artery, referred to as an ischemic stroke, or the leaking or bursting of a blood vessel, known as a hemorrhagic stroke. In some cases, individuals may experience a transient ischemic attack (TIA), a temporary disruption of blood flow to the brain.

TIAs do not typically cause lasting symptoms, but can still be a warning sign of a potential stroke and require immediate medical attention.

The most frequent type of stroke is ischemic stroke, which occurs when a significant blood vessel in the brain becomes obstructed. This obstruction may result from a blood clot, or a buildup of cholesterol and fatty deposits referred to as plaque.

A hemorrhagic stroke occurs when a blood vessel in the brain ruptures, leading to the leakage of blood into the surrounding tissue. As a result, pressure increases within the nearby brain tissue, leading to further damage and irritation.

Stroke Symptoms

Numbness or weakness in the face, arm, or leg (especially on one side of the body)
Confusion
Difficulty speaking or understanding speech
Dizziness or loss of balance
Difficulty seeing in one or both eyes
Lack of coordination
Difficulty walking
Severe headache

Subjective Data

Pain
Numbness or tingling
Decreased sensation
Headache
Nausea
Difficulty swallowing

Objective Data

Inability to control range of motion (dysmetria)
Facial droop
Paralysis on one side of the body (hemiplegia)
Paralysis
Difficulty communicating
Difficulty swallowing (dysphagia)
Vomiting
Incontinence
Difficulty moving one side of the body (hemiparesis)
Level of consciousness (LOC) changes
Poor muscle control that causes clumsy movements (ataxia)

Stroke Risk Factors

High blood pressure
Diabetes
Heart and blood vessel diseases
High LDL cholesterol levels
Smoking
History of TIAs (transient ischemic attacks)
High red blood cell count

Nursing Assessment for Stroke

Nursing assessments for stroke typically involve a comprehensive evaluation of the client’s neurological, cardiovascular, respiratory, and musculoskeletal systems, as well as their medical history, medications, and risk factors.

By performing a comprehensive nursing assessment for stroke, you can identify potential complications and develop individualized care plans to promote recovery and prevent future strokes.

Cardiac Function

Hypertension or hypotension
Heart arrhythmias
Blood Clotting
Decreased cardiac output

Respiratory function

irregular or shallow breathing
aspiration or choking
Hypoxia
pulmonary embolism

Neurologic function

paralysis, weakness, or spasticity
aphasia or dysarthria
confusion, disorientation

Sensory function

visual field deficits, double vision
hearing loss, tinnitus
numbness, tingling
vertigo, unsteadiness, or falls

Labs for Stroke

Complete blood count (CBC)
Platelet count
Serum electrolytes
Blood glucose

Stroke Nursing Interventions

Assess for neurologic dysfunction, such as level of consciousness, motor and sensory deficits, and vital signs.
Position the client properly to prevent complications such as pressure ulcers, contractures, and deep vein thrombosis. Nurses may use pillows, cushions, or splints to support proper body alignment and prevent joint deformities.
Assist with rehabilitation and therapy. Physical and occupational therapy can help clients regain motor function, balance, and mobility. Speech therapy can help clients overcome language and communication deficits.
Administer medications as prescribed.
Monitor for signs of dysphagia, and collaborate with dieticians to develop nutrition plans.
Prevent complications by prophylactic anticoagulation, infection control measures, and fall prevention strategies, to minimize the risk of complications such as deep vein thrombosis, pneumonia, or falls.

Goals and Outcomes

Maintain optimal oxygenation and prevent respiratory complications, such as pneumonia or atelectasis.
Improve the client’s ability to perform ADLs such as bathing, grooming, dressing, and feeding.
Prevent complications such as deep vein thrombosis, pressure ulcers, contractures, aspiration, or falls.
Improve the client’s ability to process information, solve problems, and perceive the environment.
Alleviate pain and discomfort associated with stroke, such as headaches, muscle spasms, or neuropathic pain.
Provide emotional and psychological support to the client and family, and address depression, anxiety, or other psychological effects of stroke.
Improve the client’s ability to move and walk safely and independently, with or without assistive devices.
Prevent future strokes by managing modifiable risk factors such as hypertension, diabetes, or hyperlipidemia.
Facilitate the client’s return to the community, including support for home care, rehabilitation, or community resources.
Improve the client’s ability to express themselves and understand language.

Stroke NCLEX Questions

Which family member statement demonstrates the need for further education regarding the care of a client diagnosed with a stroke? Select all that apply.

“Because of the visual deficits on the affected side, I will approach my spouse from the unaffected side.”
“I will encourage my spouse, who has a one-sided weakness, to dress the stronger side of the body first.”
“I will minimize any background noise when talking to my spouse due to the diagnosed receptive aphasia.”
“I will remind my spouse who neglects one side to turn the head to properly survey the surroundings.”
“I should expect my spouse to experience severe cognitive deficits due to the stroke.”

Answers: B & E

Answer B indicates a need for additional teaching as the client is taught to dress the weaker side before the stronger side of the body when unilateral weakness occurs due to a stroke.

Answer E indicates the need for additional teaching as severe cognitive impairment is not anticipated. However, some behavioral changes may occur, including a lack of impulse control in addition to a total lack of awareness of these deficits.

A right-handed client who recently experienced a stroke with severe loss of function of the right side of the body is in the rehabilitation unit. As the nurse assists with morning care, which action promotes the client’s self-esteem?

Being careful not to speak of the stroke and the new deficits.
Doing every activity for the client, including bathing and oral care.
Having the client choose which clothes to wear to rehabilitation.
Encouraging the client to do all activities of daily living without assistance.

Answer: C

Clients who experience severe changes in health and, subsequently the ability to care for themselves independently often experience changes in self-esteem. The nurse can help promote self-esteem by allowing the client to choose whenever possible, including clothing, what foods to consume, and when and where the consumption will occur.