Nursing Care Based on NANDA Nursing Diagnoses:

Impaired Gas Exchange – May be a concern due to immobility, decreased LOC

and/or ineffective cough. Monitoring airway, breathing, pulse oximetry and
arterial blood gases are essential.

Altered LOC – Frequent neurological assessments are crucial in detecting early

signs of deterioration or altered LOC. Reasons for changes can included increased
infracted brain tissue, increased ICP, fever of side effects form medications.

Altered Tissue Perfusion (cerebral) – May be related to vasospasm,

hydrocephalus, re-bleeding, or progressive stroke. Monitor LOC, Neuro
assessment and ICP and report any changes from baseline to the physician.

Risk of Infection – Infection may occur due to invasive monitoring, IV and line
placement, enteral feeding or respiratory inefficiency. Monitor for hyperthermia
and increased white blood cell count (WBC’s).

Potential for Injury – Patients may have difficulty with mobility due to
hemiplegia (paralysis on one half of the body) or hemiparesis (weakness on one
half of the body) and should be monitored closely for prevention of falls and
other injuries.

Altered Nutrition – Nutrition is a concern due to swallowing difficulties, difficulty

chewing and aspiration. The patient must have a swallowing evaluation and a
nutritional assessment to ascertain if any problems exist and if so a plan of care
needs to be formulated.

Depression – Although depression may affect the recovery period and overall
outcome after a stroke, it is often overlooked as a potential problem (which leads
to inadequate management). Stroke patients suffering from depression have been
found to have a reduced quality of life and a higher mortality rate post stroke. It
is important to identify and treat the symptoms of depression after a stroke.
Educating stroke survivors and their families to the signs, symptoms and risk of
depression after stroke may assist to increase the identification of depression and
lead to improved treatment outcomes.