Orem

ASIC CONDITIONING FACTORS
Age 56 year
GenderFemale
Health state Disability due to health condition, therapeutic self care demand
Development state Ego integrity vs despair
Sociocultural orientation No formal education, Indian, Hindu
Health care system Institutional health care
Family system Married, husband working
Patterns of living At home with partner
Environment Rural area, items for ADL not in easy reach, no special precautions to prevent injuries
Resources Husband, daughter, sister’s son
UNIVERSAL SELF-CARE REQUISITES
Air Breaths without difficulty, no pallor cyanosis
Water Fluid intake is sufficient. Edema present over ankles.Turgor normal for the age
Food Hb – 9.6gm%, BMI = 14.Food intake is not adequate or the diet is not nutritious.
Elimination Voids and eliminates bowel without difficulty.
Activity/ rest -Frequent rest is required due to pain.Pain not completely relieved, Activity level ha s
come down.Deformity of the joint secondary to the disease process and use of the joints.
Social interaction Communicates well with neighbors and calls the daughter by phone Need for
medical care is communicated to the daughter.
Prevention of hazards Need instruction on care of joints and prevention of falls. Need instruction
on improvement of nutritional status. Prefer to walk bare foot.
Promotion of normalcy Has good relation with daughter
DEVELOPMENTAL SELF-CARE REQUISITES
Maintenance of developmental environment -Able to feed self , Difficult to perform the dressing,
toileting etc
Prevention/ management of the conditions threatening the normal development -Feels that the
problems are due to her own behaviours and discusses the problems with husband and daughter.
HEALTH DEVIATION SELF CARE REQUISITES
Adherence to medical regimen Reports the problems to the physician when in the hospital.
Cooperates with the medication, Not much aware about the use and side effects of medicines
Awareness of potential problem associated with the regimen Not aware about the actual disease
process. Not compliant with the diet and prevention of hazards. Not aware about the side effects of
the medications
Modification of self image to incorporates changes in health status -- Has adapted to limitation in
mobility.The adoption of new ways for activities leads to deformities and progression of the disease.
Adjustment of lifestyle to accommodate changes in the health status and medical regimen.-Adjusted
with the deformities.Pain tolerance not achieved
5. MEDICAL PROBLEM AND PLAN
Physician’s perspective of the condition: Diagnosed with rheumatoid arthritis and is on the following
medications:
T. Valus SR OD
T. Pan 40 mg OD
T. Tramazac 50 mg OD
T. Recofix Forte BD
T. Shelcal BD
Syp. Heamup 2tsp TID
Medical Diagnosis: Rheumatoid arthritis
Medical Treatment: Medication and physical therapy.
AREAS AND PRIORITY ACCORDING TO OREM’S THEORY OF SELF-CARE DEFICIT: IMPORTANT FOR
PRIORITIZING THE NURSING DIAGNOSIS.
Air
Water
Food
Elimination
Activity/ Rest
Solitude/ Interaction
Prevention of hazards
Promotion of normalcy
Maintain a developmental environment.
Prevent or manage the developmental threats
Maintenance of health status
Awareness and management of the disease process.
Adherence to the medical regimen
Awareness of potential problem.

modify self image
Adjust life style to accommodate health status changes and MR
NURSING CARE PLAN ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT
Nursing diagnosis Outcome and Implementation Evaluation

(diagnostic plan (control (regulatory
operations) (Prescriptive operations) operations)
operations)
Based on self care Nursing goal and Nurse- patient Effectiveness of
deficits objectives actions to the nurse
Design of nursing - Promote patient action to
Outcome system patient as self -Promote
Appropriate care agent patient as self
1. Effectiveness of method of - Meet self care care agent
the nurse patient helping needs - Meet self
action to - Decrease the care needs
-Promote patient as self care deficit. - Decrease the
self care agent self care deficit.
- Meet self care 2. Effectiveness
needs of the selected
- Decrease the self nursing system
care deficit. to meet the
needs.
Thus in the patient Mrs. X the areas that need assistance were…
Air
Water
Food
Elimination
Activity/ Rest(2)
Solitude/ Interaction
Prevention of hazards(2)
Promotion of normalcy
Maintain a developmental environment.
Prevent or manage the developmental threats
Maintenance of health status
Awareness and management of the disease process.
Adherence to the medical regimen
Awareness of potential problem.
modify self image
Adjust life style to accommodate health status changes and medical regimen
. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: FOOD
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS:-Inability to maintain the ideal nutrition related to inadequate intake and
knowledge deficit
OUTCOMES AND PLAN
a. Outcome:
Improved nutrition
Maintenance of a balanced diet with adequate iron supplementation.
b. Nursing Goals and objectives
oal: to achieve optimal levels of nutrition.
Objectives: Mrs. X will:
state the importance of maintaining a balanced diet.
List the food items rich in iron , that are available in the locality.
c. Design of the nursing system:
oal: to achieve optimal levels of nutrition.
state the importance of maintaining a balanced diet.
List the food items rich in iron , that are available in the locality.
c. Design of the nursing system:

supportive educative
d. Method of helping:
guidance
support
Teaching
Providing developmental environment
IMPLEMENTATION
Mutually planned and identified the objectives and the patient were made to understand about the
required changes in the behaviour to have the requisites met.
EVALUATION
Mrs. X understood the importance of maintaining an optimum nutrition.
She told that she will select the iron rich diet for her food.
She listed the foods that are rich in iron and that are locally available.
The self care deficit in terms of food will be decreased with the initiation of the nutritional intake.
The supportive educative system was useful for Mrs. X
HERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: ACTIVITY
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSISSelf-care deficit: dressing, toileting related to restricted joint movement,

secondary to the inflammatory process in the joints.
OUTCOMES AND PLAN
a. Outcome:
improved self-care
maintain the ability to perform the toileting and dressing with modification as required.
b. Nursing Goals and objectives
Goal: to achieve optimal levels of ability for self care.
perform the dressing activities within limitations
utilize the alternative measures available for improving the toileting
perform the other activities of daily living with minimal assistance.
c. Design of the nursing system: Partly compensatory

d. Method of helping:
1. Guidance:
Assess the various hindering factors for self care and how to tackle them.
Support:
Provide all the articles needed for self care, near to the patient and ask the family members also to
give the articles near to her.
Provide passive exercises and make to perform active exercises so as to promote the mobility of the
joint.
Make the patient use commodes or stools to perform toileting and insist on avoidance of squatting
position
Provide assistance whenever needed for the self care activities
Provide encouragement and positive reinforcement for minor improvement in the activity level.
Initiate the pain relieving measures always before the patient go for any of the activities of daily
living
M Teaching:
Teach the family members the limitation in the activity level the patient has and the cooperation
required
4. Promoting a developmental environment:
Teach the family and help them to practice how to help the patient according to her needs
IMPLEMENTATION
Mutually planned and identified the objectives and the patient was made to understand about the
required changes in the behaviour to have the requisites met.t
ake the patient to use loose fitting clothes which will be easy to wear and remove.
EVALUATION
Patient was performing some of the activities and she practiced toileting using a commode in the
hospital.
She verbalized an improved comfort and self care ability.
She performed the dressing activities with minimal assistance
Patient verbalized that she will perform the activities as instructed to get her ADL done.
The partly compensatory system was useful for Mrs. X

efinition • A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of
brain function resulting from a disruption of the blood supply to a part of the brain either by a
blockage or the rupture of a blood vessel. • It is a functional abnormality ofthe central nervous
system.
3. Types of CVA There are two main types of CVA or stroke: • Ischemic stroke is caused by a
blockage; • Hemorrhagic stroke is caused by the rupture of a blood vessel. Both types of stroke
deprive part of the brain of blood and oxygen, causing brain cells to die.
4. Ischemic stroke • An ischemic stroke is the most common and occurs when a blood clot blocks a
blood vessel and prevents blood and oxygen from getting to a part of the brain.
5. Ischemic stroke • Two ways for Ischemic stroke  Embolic stroke, which occurs when a clot forms
somewhere else in your body and gets lodged in a blood vessel in the brain. Thrombotic stroke,
which occurs when the clot forms in a blood vessel within the brain.
6. Hemorrhagic stroke • A hemorrhagic stroke occurs when a blood vessel ruptures, or hemorrhages,
and then prevents blood from getting to part of the brain. • The hemorrhage may occur in any blood
vessel in the brain, or it may occur in the membrane surrounding the brain.
7. Risk Factors The following are the nonmod11111111111111111111111ifiable and modifiable risk
factors of Cerebrovascular accident: Nonmodifiable • Advanced age (older than 55 years) • Gender
(Male) • Race (African American)
8. Risk Factors Modifiable • Hypertension • Atrial fibrillation • Hyperlipidemia • Obesity • Smoking •

Diabetes • Asymptomatic carotid stenosis and valvular heart disease (eg, endocarditis, prosthetic
heart valves)
9. Pathophysiology • The disruption in the blood flow initiates a complex series of cellular metabolic
events. • Decreased cerebral blood flow. The ischemic cascade begins when cerebral blood flow
decreases to less than 25 mL per 100g of blood per minute. • Aerobic respiration. At this point,
neurons are unable to maintain aerobic respiration.
10. Pathophysiology • Anaerobic respiration. The mitochondria would need to switch to anaerobic
respiration, which generates large amounts of lactic acid, causing a change in pH and rendering the
neurons incapable of producing sufficient quantities of ATP. • Loss of function. The membrane
pumps that maintain electrolyte balances fail and the cells cease to function.
11. Pathophysiology The disruption in the blood flow initiates a complex series of cellular metabolic
events.
12. Causes Strokes are caused by the following: • Large artery thrombosis. Large artery thromboses
are caused by atherosclerotic plaques in the large blood vessels of the brain. • Small penetrating
artery thrombosis. Small penetrating artery thrombosis affects one or more vessels and is the most
common type of ischemic stroke. • Cardiogenic emboli. Cardiogenic emboli are associated with
cardiac dysrhythmias, usually atrial fibrillation.
13. Clinical Manifestations The quicker you can get a diagnosis and treatment for a stroke, the better
your prognosis will be. For this reason, it’s important to understand and recognize the symptoms of
a stroke.
14. Symptoms of CVA General sign & symptoms includes • Difficulty walking • Dizziness • loss of
balance and coordination • Difficulty speaking or understanding others who are speaking •
Numbness or paralysis in the face, leg, or arm, most likely on just one side of the body • Blurred or
darkened vision
15. Symptoms of CVA • A sudden headache, especially when accompanied by nausea, vomiting, or
dizziness • The symptoms of a stroke can vary depending on the individual and where in the brain it
has happened. Symptoms usually appear suddenly, even if they’re not very severe, and they may
become worse over time.
16. Symptoms of CVA • Remembering the acronym “FAST” helps people recognize the most
common symptoms of stroke: • Face: Does one side of the face droop? • Arm: If a person holds both
arms out, does one drift downward? • Speech: Is their speech abnormal or slurred? • Time: It’s time
to call 911 and get to the hospital if any of these symptoms are present.
17. Diagnosis of CVA • Healthcare providers have a number of tools to determine whether you’ve
had a stroke. • Healthcare provider will administer a full physical examination, during which they’ll
check patient’s strength, reflexes, vision, speech, and senses.
18. Diagnosis of CVA • They’ll also check for a particular sound in the blood vessels of your neck. This
sound, which is called a bruit, indicates abnormal blood flow. • Finally, they will check your blood
pressure, which may be high if you’ve had a stroke.
19. Diagnosis of CVA • Blood tests: Blood test for clotting time, blood sugar levels, or infection. These
can all affect the likelihood and progression of a stroke. • Angiogram: An angiogram, which involves
adding a dye to your blood and taking an X-ray of your head, can help your doctor find the blocked
or hemorrhaged blood vessel.
20. Diagnosis of CVA • Blood tests: Blood test for clotting time, blood sugar levels, or infection. These
can all affect the likelihood and progression of a stroke. • Angiogram: An angiogram, which involves
adding a dye to your blood and taking an X-ray of your head, can help your doctor find the blocked
or hemorrhaged blood vessel.
21. Diagnosis of CVA • Carotid ultrasound: This test uses sound waves to create images of the blood
vessels in your neck. This test can help your provider determine if there’s abnormal blood flow
toward your brain. • CT scan: A CT scan is often performed soon after symptoms of a stroke develop.
The test can help provider find the problem area or other problems that might be associated with
stroke.
22. Diagnosis of CVA • MRI scan : An MRI can provide a more detailed picture of the brain compared
to CT scan. It’s more sensitive than a CT scan in being able to detect a stroke. • Echocardiogram :
This imaging technique uses sound waves to create a picture of your heart. It can help your provider
find the source of blood clots.
23. Diagnosis of CVA • Electrocardiogram (EKG): This is an electrical tracing of your heart. This will
help your healthcare provider determine if an abnormal heart rhythm is the cause of a stroke.
24. Treatment for CVA • The goal of treatment for ischemic stroke, for instance, is to restore the
blood flow. • Treatment for stroke depends on the type of stroke you’ve had. • Treatments for
hemorrhagic stroke are aimed at controlling the bleeding.
25. Ischemic stroke treatment • To treat an ischemic stroke, you may be given a clot-dissolving drug
or a blood thinner. • You may also be given aspirin to prevent a second stroke. • Emergency
treatment for this type of stroke may include injecting medicine into the brain or removing a
blockage with a procedure.
26. Hemorrhagic stroke treatment • For a hemorrhagic stroke, patient may be given a drug that
lowers the pressure in brain caused by the bleeding. • If the bleeding is severe, patient may need
surgery to remove excess blood. • It’s also possible that patient will need surgery to repair the
ruptured blood vessel.
27. Medical Management Medical management for secondary prevention. • Recombinant tissue
plasminogen activator would be prescribed unless contraindicated, and there should be monitoring
for bleeding. • Increased ICP. Management of increased ICP includes osmotic diuretics, maintenance
of PaCO2 at 30-35 mmHg, and positioning to avoid hypoxia through elevation of the head of the bed.
28. Medical Management • Endotracheal Tube. There is a possibility of intubation to establish

patent airway if necessary. • Hemodynamic monitoring. Continuous hemodynamic monitoring
should be implemented to avoid an increase in blood pressure. • Neurologic assessment to
determine if the stroke is evolving and if other acute complications are developing
29. Nursing Management After the stroke is complete, management focuses on the prompt initiation
of rehabilitation for any deficits. Nursing Assessment • During the acute phase, a neurologic flow
sheet is maintained to provide data about the following important measures of the patient’s clinical
status: • Change in level of consciousness or responsiveness.
30. Nursing Assessment • Presence or absence of voluntary or involuntary movements of

extremities. • Stiffness or flaccidity of the neck. • Eye opening, comparative size of pupils, and
pupillary reaction to light.
31. Nursing Assessment • Color of the face and extremities; temperature and moisture of the skin. •
Ability to speak. • Presence of bleeding. • Maintenance of blood pressure.
32. Nursing Assessment • During the postacute phase, assess the following functions: • Mental
status (memory, attention span, perception, orientation, affect, speech/language). • Sensation and
perception (usually the patient has decreased awareness of pain and temperature).
33. Nursing Assessment • Motor control (upper and lower extremity movement); swallowing ability,
nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function. •
Continue focusing nursing assessment on impairment of function in patient’s daily activities.
34. Nursing Diagnosis • Based on the assessment data, the major nursing diagnoses for a patient
with stroke may include the following: • Impaired physical mobility elated to hemiparesis, loss of
balance and coordination, spasticity, and brain injury. • Acute pain related to hemiplegia and disuse.
• Disturbed sensory perception related to altered sensory reception, transmission, and/or
integration.
35. Nursing Diagnosis • Impaired urinary elimination related to flaccid bladder detrusor instability,
confusion, or difficulty in communicating. • Disturbed thought processes related to brain damage. •
Impaired verbal communication related to brain damage.
36. Nursing Diagnosis • Risk for impaired skin integrity elated to hemiparesis or hemiplegia and
decreased mobility. • Interrupted family processes related to catastrophic illness and caregiving
burdens. • Sexual dysfunction elated to neurologic deficits or fear of failure.
37. Nursing plannings The major nursing care planning 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.
38. Nursing planning • Continence of bowel and bladder. • Improved thought processes. • Achieving
a form of communication. • Maintaining skin integrity. • Restore family functioning. • Improve
sexual function. • Absence of complications.
39. Nursing Interventions • Nursing care has a significant impact on the patient’s recovery. In
summary, here are some nursing interventions for patients with stroke: • Positioning. Position to
prevent contractures, relieve pressure, attain good body alignment, and prevent compressive
neuropathies. • Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.
40. Nursing Interventions • Prevent adduction. Prevent adduction of the affected shoulder with a
pillow placed in the axilla. • Prevent edema. Elevate affected arm to prevent edema and fibrosis. •
Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
41. Nursing Interventions • Prevent venous stasis. Exercise is helpful in preventing venous stasis,
which may predispose the patient to thrombosis and pulmonary embolus. • Regain balance. Teach
patient to maintain balance in a sitting position, then to balance while standing and begin walking as
soon as standing balance is achieved. • Personal hygiene. Encourage personal hygiene activities as
soon as the patient can sit up.
42. Nursing Interventions • Manage sensory difficulties. Approach patient with a decreased field of
vision on the side where visual perception is intact. • Visit a speech therapist. Consult with a speech
therapist to evaluate gag reflexes and assist in teaching alternate swallowing techniques. • Voiding
pattern. Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
43. Nursing Interventions • Be consistent in patient’s activities. Be consistent in the schedule,

routines, and repetitions; a written schedule, checklists, and audiotapes may help with memory and
concentration, and a communication board may be used. • Assess skin. Frequently assess skin for
signs of breakdown, with emphasis on bony areas and dependent body parts.
44. Evaluation Expected patient outcomes may include the following: • Improved mobility. •
Absence of shoulder pain. • Self-care achieved. • Relief of sensory and perceptual deprivation. •
Prevention of aspiration.
45. Evaluation • Continence of bowel and bladder. • Improved thought processes. • Achieved a form
of communication. • Maintained skin integrity. • Restored family functioning. • Improved sexual
function. • Absence of complications.
46. Complications • If cerebral oxygenation is still inadequate; complications may occur. • Tissue
ischemia. If cerebral blood flow is inadequate, the amount of oxygen supplied to the brain is
decreased, and tissue ischemia will result. • Cardiac dysrhythmias. The heart compensates for the
decreased cerebral blood flow, and with too much pumping, dysrhythmias may occur.
47. Prevention of a CVA • Maintain normal blood pressure. • Refrain from smoking, and drink
alcohol in moderation •
48. Prevention of a CVA • DASH diet. The DASH (Dietary Approaches to Stop Hypertension) diet is
high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein and can
lower the risk of stroke. • Stroke risk screenings. Stroke risk screenings are an ideal opportunity to
lower stroke risk by identifying people or groups of people who are at high risk for stroke.
49. Prevention of a CVA • Education. Patients and the community must be educated about
recognition and prevention of stroke. • Low-dose aspirin. Research findings suggest that low-dose
aspirin may lower the risk of stroke in women who are at risk.
50. Prevention of a CVA • Your healthcare provider may prescribe medications for preventing stroke
if they know you’re at risk. • Possible preventive medications for stroke include drugs that thin the
blood and prevent clot formation.
51. Discharge and Home Care Guidelines • Patient and family education is a fundamental
component of rehabilitation. • Consult an occupational therapist. An occupational therapist may be
helpful in assessing the home environment and recommending modifications to help the patient
become more independent. • Physical therapy. A program of physical therapy may be beneficial,
whether it takes place in the home or in an outpatient program.
52. Discharge and Home Care Guidelines • Antidepressant therapy. Depression is a common and
serious problem in the patient who has had a stroke. • Support groups. Community-based stroke
support groups may allow the patient and the family to learn from others with similar problems and
to share their experiences.
53. Discharge and Home Care Guidelines • Assess caregivers. Nurses should assess caregivers for
signs of depression, as depression is also common among caregivers of stroke survivors.
A cerebrovascular accident (CVA), an ischemic stroke or brain attack, is a sudden loss of brain
function resulting from a disruption of the blood supply to a part of the brain.
Cerebrovascular accident or stroke is the primary cerebrovascular disorder in the United States.
A cerebrovascular accident is a sudden loss of brain functioning resulting from a disruption of the
blood supply to a part of the brain.
It is a functional abnormality of the central nervous system.
Cryptogenic strokes have no known cause, and other strokes result from causes such as illicit drug
use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.
The result is an interruption in the blood supply to the brain, causing temporary or permanent loss
of movement, thought, memory, speech, or sensation.
Classification
Strokes can be divided into two classifications.
Ischemic stroke. This is the loss of function in the brain as a result of a disrupted blood supply.
Hemorrhagic stroke. Hemorrhagic strokes are caused by bleeding into the brain tissue, the
ventricles, or the subarachnoid space.
Risk Factors
The following are the nonmodifiable and modifiable risk factors of Cerebrovascular accident:
Nonmodifiable
Advanced age (older than 55 years)
Gender (Male)
Race (African American)
Modifiable
Hypertension
Atrial fibrillation
Hyperlipidemia
Obesity
Smoking
Diabetes
Asymptomatic carotid stenosis and valvular heart disease (eg, endocarditis, prosthetic heart valves)
Periodontal disease
Pathophysiology
The disruption in the blood flow initiates a complex series of cellular metabolic events. Decreased
cerebral blood flow. The ischemic cascade begins when cerebral blood flow decreases to less than 25
mL per 100g of blood per minute.
Aerobic respiration. At this point, neurons are unable to maintain aerobic respiration.
Anaerobic respiration. The mitochondria would need to switch to anaerobic respiration, which
generates large amounts of lactic acid, causing a change in pH and rendering the neurons incapable
of producing sufficient quantities of ATP.
Loss of function. The membrane pumps that maintain electrolyte balances fail and the cells cease to
function.
Causes
Strokes are caused by the following:
Large artery thrombosis. Large artery thromboses are caused by atherosclerotic plaques in the large
blood vessels of the brain.
Small penetrating artery thrombosis. Small penetrating artery thrombosis affects one or more
vessels and is the most common type of ischemic stroke.
Cardiogenic emboli. Cardiogenic emboli are associated with cardiac dysrhythmias, usually atrial
fibrillation.
Clinical Manifestations
Stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion, the
size of the area of inadequate perfusion, and the amount of the collateral blood flow. General signs
and symptoms include numbness or weakness of face, arm, or leg (especially on one side of the
body); confusion or change in mental status; trouble speaking or understanding speech; visual
disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache.
Recognizing Stroke
Recognizing Stroke: BEFAST
General signs and symptoms include numbness or weakness of face, arm, or leg (especially on one
side of the body); confusion or change in mental status; trouble speaking or understanding speech;
visual disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache.
Numbness or weakness of the face. Without adequate perfusion, oxygen is also low, and facial
tissues could not function properly without them.
Change in mental status. Due to decreased oxygen, the patient experiences confusion.
Trouble speaking or understanding speech. Cells cease to function as a result of inadequate

perfusion.
Visual disturbances. The eyes also need enough oxygen for optimal functioning.
Homonymous hemianopsia. There is loss of half of the visual field.
Loss of peripheral vision. The patient experiences difficulty seeing at night and is unaware of objects
or the borders of objects.
Hemiparesis. There is a weakness of the face, arm, and leg on the same side due to a lesion in the
opposite hemisphere.
Hemiplegia. Paralysis of the face, arm, and leg on the same side due to a lesion in the opposite
hemisphere.
Ataxia. Staggering, unsteady gait and inability to keep feet together.
Dysarthria. This is the difficulty in forming words.
Dysphagia. There is difficulty in swallowing.
Paresthesia. There is numbness and tingling of extremities and difficulty with proprioception.
Expressive aphasia. The patient is unable to form words that is understandable yet can speak in
single-word responses.
Receptive aphasia. The patient is unable to comprehend the spoken word and can speak but may
not make any sense.
Global aphasia. This is a combination of both expressive and receptive aphasia.
Motor Loss
Hemiplegia, hemiparesis
Flaccid paralysis and loss of or decrease in the deep tendon reflexes (initial clinical feature) followed
by (after 48 hours) reappearance of deep reflexes and abnormally increased muscle tone (spasticity)
Communication Loss
Dysarthria (difficulty speaking)
Dysphasia (impaired speech) or aphasia (loss of speech)
Apraxia (inability to perform a previously learned action)
Perceptual Disturbances and Sensory Loss
Visual-perceptual dysfunctions (homonymous hemianopia [loss of half of the visual field])
Disturbances in visual-spatial relations (perceiving the relation of two or more objects in spatial
areas), frequently seen in patients with right hemispheric damage
Sensory losses: slight impairment of touch or more severe with loss of proprioception; difficulty in
interrupting visual, tactile, and auditory stimuli
Impaired Cognitive and Psychological Effects
Frontal lobe damage: Learning capacity, memory, or other higher cortical intellectual functions may
be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in
comprehension, forgetfulness, and lack of motivation.
Depression, other psychological problems: emotional lability, hostility, frustration, resentment, and
lack of cooperation.
Prevention
Primary prevention of stroke remains the best approach.
Preventing Stroke
Prevention of stroke.
Healthy lifestyle. Leading a healthy lifestyle which includes not smoking, maintaining a healthy
weight, following a healthy diet, and daily exercise can reduce the risk of having a stroke by about
one half.
DASH diet. The DASH (Dietary Approaches to Stop Hypertension) diet is high in fruits and vegetables,
moderate in low-fat dairy products, and low in animal protein and can lower the risk of stroke.
Stroke risk screenings. Stroke risk screenings are an ideal opportunity to lower stroke risk by
identifying people or groups of people who are at high risk for stroke.
Education. Patients and the community must be educated about recognition and prevention of
stroke.
Low-dose aspirin. Research findings suggest that low-dose aspirin may lower the risk of stroke in
women who are at risk.
Complications
If cerebral oxygenation is still inadequate; complications may occur.
Tissue ischemia. If cerebral blood flow is inadequate, the amount of oxygen supplied to the brain is
decreased, and tissue ischemia will result.
Cardiac dysrhythmias. The heart compensates for the decreased cerebral blood flow, and with too
much pumping, dysrhythmias may occur.
Assessment and Diagnostic Findings
Any patient with neurologic deficits needs a careful history and complete physical and neurologic
examination.
CT scan. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions.

Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions. Note: May
not immediately reveal all changes, e.g., ischemic infarcts are not evident on CT for 8-12 hr;
however, intracerebral hemorrhage is immediately apparent; therefore, emergency CT is always
done before administering tissue plasminogen activator (t-PA). In addition, patients with TIA
commonly have a normal CT scan
PET scan. Provides data on cerebral metabolism and blood flow changes.
MRI. Shows areas of infarction, hemorrhage, AV malformations, and areas of ischemia.
Cerebral angiography. Helps determine specific cause of stroke, e.g., hemorrhage or obstructed
artery, pinpoints site of occlusion or rupture. Digital subtraction angiography evaluates patency of
cerebral vessels, identifies their position in head and neck, and detects/evaluates lesions and
vascular abnormalities.
Lumbar puncture. Pressure is usually normal and CSF is clear in cerebral thrombosis, embolism, and
TIA. Pressure elevation and grossly bloody fluid suggest subarachnoid and intracerebral hemorrhage.
CSF total protein level may be elevated in cases of thrombosis because of inflammatory process. LP
should be performed if septic embolism from bacterial endocarditis is suspected.
Transcranial Doppler ultrasonography. Evaluates the velocity of blood flow through major
intracranial vessels; identifies AV disease, e.g., problems with carotid system (blood flow/presence
of atherosclerotic plaques).
EEG. Identifies problems based on reduced electrical activity in specific areas of infarction; and can
differentiate seizure activity from CVA damage.
Skull x-ray. May show a shift of pineal gland to the opposite side from an expanding mass;
calcifications of the internal carotid may be visible in cerebral thrombosis; partial calcification of
walls of an aneurysm may be noted in subarachnoid hemorrhage.
ECG and echocardiography. To rule out cardiac origin as source of embolus (20% of strokes are the
result of blood or vegetative emboli associated with valvular disease, dysrhythmias, or endocarditis).
Laboratory studies to rule out systemic causes: CBC, platelet and clotting studies, VDRL/RPR,
erythrocyte sedimentation rate (ESR), chemistries (glucose, sodium).
Medical Management
Patients who have experienced TIA or stroke should have medical management for secondary
prevention.
Recombinant tissue plasminogen activator would be prescribed unless contraindicated, and there
should be monitoring for bleeding.
Increased ICP. Management of increased ICP includes osmotic diuretics, maintenance of PaCO2 at
30-35 mmHg, and positioning to avoid hypoxia through elevation of the head of the bed.
Endotracheal Tube. There is a possibility of intubation to establish patent airway if necessary.
Hemodynamic monitoring. Continuous hemodynamic monitoring should be implemented to avoid

an increase in blood pressure.
Neurologic assessment to determine if the stroke is evolving and if other acute complications are
developing
Surgical Management
Surgical management may include prevention and relief from increased ICP.
Carotid endarterectomy. This is the removal of atherosclerotic plaque or thrombus from the carotid
artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.
Hemicraniectomy. Hemicraniectomy may be performed for increased ICP from brain edema in
severe cases of stroke.
Nursing Management
After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any
deficits.
Nursing Assessment
During the acute phase, a neurologic flow sheet is maintained to provide data about the following
important measures of the patients clinical status:
Change in level of consciousness or responsiveness.
Presence or absence of voluntary or involuntary movements of extremities.
Stiffness or flaccidity of the neck.
Eye opening, comparative size of pupils, and pupillary reaction to light.
Color of the face and extremities; temperature and moisture of the skin.
Ability to speak.
Presence of bleeding.
Maintenance of blood pressure.
During the postacute phase, assess the following functions:
Mental status (memory, attention span, perception, orientation, affect, speech/language).
Sensation and perception (usually the patient has decreased awareness of pain and temperature).
Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration
status, skin integrity, activity tolerance, and bowel and bladder function.
Continue focusing nursing assessment on impairment of function in patients daily activities.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses for a patient with stroke may include the
following:
Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and
brain injury.
Acute pain related to hemiplegia and disuse.
Deficient self-care related to stroke sequelae.
Disturbed sensory perception related to altered sensory reception, transmission, and/or integration.
Impaired urinary elimination related to flaccid bladder, detrusor instability, confusion, or difficulty in
communicating.
Disturbed thought processes related to brain damage.
Impaired verbal communication related to brain damage.
Risk for impaired skin integrity related to hemiparesis or hemiplegia and decreased mobility.
Interrupted family processes related to catastrophic illness and caregiving burdens.
Sexual dysfunction related to neurologic deficits or fear of failure.
Nursing Care Planning & Goals
Main article: Cerebrovascular Accident (Stroke) Nursing Care Plans
The major nursing care planning goals for the patient and family may include:
Improve mobility.
Avoidance of shoulder pain.
Achievement of self-care.
Relief of sensory and perceptual deprivation.
Continence of bowel and bladder.
Improved thought processes.
Achieving a form of communication.
Maintaining skin integrity.
Restore family functioning.
Improve sexual function.
Absence of complications.
Nursing Interventions
Nursing care has a significant impact on the patients recovery. In summary, here are some nursing
interventions for patients with stroke:
Positioning. Position to prevent contractures, relieve pressure, attain good body alignment, and
prevent compressive neuropathies.
Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.
Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed in the axilla.
Prevent edema. Elevate affected arm to prevent edema and fibrosis.
Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the
patient to thrombosis and pulmonary embolus.
Regain balance. Teach patient to maintain balance in a sitting position, then to balance while
standing and begin walking as soon as standing balance is achieved.
Personal hygiene. Encourage personal hygiene activities as soon as the patient can sit up.
Manage sensory difficulties. Approach patient with a decreased field of vision on the side where
visual perception is intact.
Visit a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in
teaching alternate swallowing techniques.
Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on patients voiding schedule.
Be consistent in patients activities. Be consistent in the schedule, routines, and repetitions; a written
schedule, checklists, and audiotapes may help with memory and concentration, and a
communication board may be used.
Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and
dependent body parts.
Improving Mobility and Preventing Deformities
Position to prevent contractures; use measures to relieve pressure, assist in maintaining good body
alignment, and prevent compressive neuropathies.
Apply a splint at night to prevent flexion of affected extremity.
Prevent adduction of the affected shoulder with a pillow placed in the axilla.
Elevate affected arm to prevent edema and fibrosis.
Position fingers so that they are barely flexed; place hand in slight supination. If upper extremity
spasticity is noted, do not use a hand roll; dorsal wrist splint may be used.
Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a
day.
Establishing an Exercise Program
Provide full range of motion four or five times a day to maintain joint mobility, regain motor control,
prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular
system, and enhance circulation. If tightness occurs in any area, perform a range of motion exercises
more frequently.
Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and
pulmonary embolus.
Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (e.g.,
shortness of breath, chest pain, cyanosis, and increasing pulse rate).
Supervise and support the patient during exercises; plan frequent short periods of exercise, not
longer periods; encourage the patient to exercise unaffected side at intervals throughout the day.
Preparing for Ambulation
Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is
gone, when indicated).
Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt table
if needed).
Begin walking as soon as standing balance is achieved (use parallel bars and have a wheelchair
available in anticipation of possible dizziness).
Keep training periods for ambulation short and frequent.
Preventing Shoulder Pain
Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder.
Use proper patient movement and positioning (e.g., flaccid arm on a table or pillows when patient is
seated, use of sling when ambulating).
Range of motion exercises are beneficial, but avoid over strenuous arm movements.
Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as
indicated.
Enhancing Self Care
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Encourage personal hygiene activities as soon as the patient can sit up; select suitable self-care
activities that can be carried out with one hand.
Help patient to set realistic goals; add a new task daily.
As a first step, encourage patient to carry out all self-care activities on the unaffected side.
Make sure patient does not neglect affected side; provide assistive devices as indicated.
Improve morale by making sure patient is fully dressed during ambulatory activities.
Assist with dressing activities (e.g., clothing with Velcro closures; put garment on the affected side
first); keep environment uncluttered and organized.
Provide emotional support and encouragement to prevent fatigue and discouragement.
Managing Sensory-Perceptual Difficulties
Approach patient with a decreased field of vision on the side where visual perception is intact; place
all visual stimuli on this side.
Teach patient to turn and look in the direction of the defective visual field to compensate for the
loss; make eye contact with patient, and draw attention to affected side.
Increase natural or artificial lighting in the room; provide eyeglasses to improve vision.
Remind patient with hemianopsia of the other side of the body; place extremities so that patient can
see them.
Assisting with Nutrition
Observe patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth,
food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
Consult with speech therapist to evaluate gag reflexes; assist in teaching alternate swallowing
techniques, advise patient to take smaller boluses of food, and inform patient of foods that are
easier to swallow; provide thicker liquids or pureed diet as indicated.
Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated.
Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check
tube position before feeding, administer feeding slowly, and ensure that cuff of tracheostomy tube
is inflated (if applicable); monitor and report excessive retained or residual feeding.
Attaining Bowel and Bladder Control
Perform intermittent sterile catheterization during the period of loss of sphincter control.
Analyze voiding pattern and offer urinal or bedpan on patients voiding schedule.
Assist the male patient to an upright posture for voiding.
Provide highfiber diet and adequate fluid intake (2 to 3 L/day), unless contraindicated.
Establish a regular time (after breakfast) for toileting.
Improving Thought Processes
Reinforce structured training program using cognitive, perceptual retraining, visual imagery, reality
orientation, and cueing procedures to compensate for losses.
Support patient: Observe performance and progress, give positive feedback, convey an attitude of
confidence and hopefulness; provide other interventions as used for improving cognitive function
after a head injury.
Improving Communication
Reinforce the individually tailored program.
Jointly establish goals, with the patient taking an active part.

Make the atmosphere conducive to communication, remaining sensitive to patients reactions and
needs and responding to them in an appropriate manner; treat the patient as an adult.
Provide strong emotional support and understanding to allay anxiety; avoid completing patients
sentences.
Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes
may help with memory and concentration; a communication board may be used.
Maintain patients attention when talking with the patient, speak slowly, and give one instruction at a
time; allow the patient time to process.
Talk to aphasic patients when providing care activities to provide social contact.
Maintaining Skin Integrity
Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body
parts.
Employ pressure relieving devices; continue regular turning and positioning (every 2 hours
minimally); minimize shear and friction when positioning.
Keep skin clean and dry, gently massage the healthy dry skin and maintain adequate nutrition.
Improving Family Coping
Provide counseling and support to the family.
Involve others in patients care; teach stress management techniques and maintenance of personal
health for family coping.
Give family information about the expected outcome of the stroke, and counsel them to avoid doing
things for the patient that he or she can do.
Develop attainable goals for the patient at home by involving the total health care team, patient,
and family.
Encourage everyone to approach the patient with a supportive and optimistic attitude, focusing on
abilities that remain; explain to the family that emotional lability usually improves with time.
Helping the Patient Cope with Sexual Dysfunction
Perform indepth assessment to determine sexual history before and after the stroke.
Interventions for patient and partner focus on providing relevant information, education,
reassurance, adjustment
of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and a
means of sexual expression and satisfaction.
Teaching points
Teach patient to resume as much self care as possible; provide assistive devices as indicated.
Have occupational therapist make a home assessment and recommendations to help the patient
become more independent.
Coordinate care provided by numerous health care professionals; help family plan aspects of care.
Advise family that patient may tire easily, become irritable and upset by small events, and show less
interest in daily events.
Make a referral for home speech therapy. Encourage family involvement. Provide family with
practical instructions to help patient between speech therapy sessions.
Discuss patients depression with the physician for possible antidepressant therapy.
Encourage patient to attend community-based stroke clubs to give a feeling of belonging and
fellowship to others.
Encourage patient to continue with hobbies, recreational and leisure interests, and contact with
friends to prevent social isolation.
Encourage family to support patient and give positive reinforcement.
Remind spouse and family to attend to personal health and wellbeing.
Evaluation
Expected patient outcomes may include the following:
Improved mobility.
Absence of shoulder pain.
Self-care achieved.
Relief of sensory and perceptual deprivation.
Continence of bowel and bladder.
Improved thought processes.
Achieved a form of communication.
Maintained skin integrity.
Restored family functioning.
Improved sexual function.
Absence of complications.
Discharge and Home Care Guidelines
Patient and family education is a fundamental component of rehabilitation.

Consult an occupational therapist. An occupational therapist may be helpful in assessing the home
environment and recommending modifications to help the patient become more independent.
Physical therapy. A program of physical therapy may be beneficial, whether it takes place in the
home or in an outpatient program.
Antidepressant therapy. Depression is a common and serious problem in the patient who has had a
stroke.
Support groups. Community-based stroke support groups may allow the patient and the family to
learn from others with similar problems and to share their experiences.
Assess caregivers. Nurses should assess caregivers for signs of depression, as depression is also
common among caregivers of stroke survivors.
Documentation Guidelines
The focus of documentation should involve:
Individual findings including level of function and ability to participate in specific or desired activities.
Needed resources and adaptive devices.
Results of laboratory tests, diagnostic studies, and mental status or cognitive evaluation.
SO/family support and participation.
Plan of care and those involved in planning.
Teaching plan.
Response to interventions, teaching, and actions performed.
Attainment or progress toward desired outcomes.
Modifications to plan of care.
Practice Quiz: Cerebrovascular Accident (Stroke)
Heres a 5-item practice quiz for this Cerebrovascular Accident (Stroke) Study Guide. Please visit our
nursing test bank for more NCLEX practice questions.
1. As a cause of death in the United States, stroke currently ranks:
A. Second
B. Third
C. Fourth
D. Fifth
2. The most common cause of cerebrovascular accident is:
A. Arteriosclerosis
B. Embolism
C. Hypertensive changes
D. Vasospasm
3. The degree of neurologic damage that occurs with an ischemic stroke depends on the:
A. Location of the lesion.
B. Size of the area of inadequate perfusion.
C. Amount of collateral blood flow.
D. Combination of the above factors.
4. The most common side effect of tPA is:
A. An allergic reaction.
B. Bleeding.
C. Severe vomiting.
D. A second stroke in 6 to 12 hours.
5. The majority of strokes have what type of origin?
A. Cardiogenic emboli.
B. Cryptogenic.
C. Large artery thrombotic.
D. Small artery thrombotic.

Answers and Rationale
1. Answer: B. Third
B: Stroke is the third leading cause of death after heart disease and cancer.
A: Cancer is the second leading cause of death in the United States.
C: Stroke is not the fourth leading cause of death in the United States.
D: Stroke is not the fifth leading cause of death in the United States.
2. Answer: A. Arteriosclerosis
A: Small penetrating artery thrombosis affects one or more vessels and is the most common cause of
cerebrovascular accident.
B: Embolism is not the most common cause of cerebrovascular accident.
C: Hypertensive changes are not the most common cause of cerebrovascular accident.
D: Vasospasm is not the most common cause of cerebrovascular accident.
3. Answer: D. Combination of the above factors.
D: Stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion, the
size of the area of inadequate perfusion, and the amount of the collateral blood flow.
A: The degree of neurologic damage that occurs with an ischemic stroke depends on the location of
the lesion.
B: The degree of neurologic damage that occurs with an ischemic stroke depends on the size of the
area of inadequate perfusion.
C: The degree of neurologic damage that occurs with an ischemic stroke depends on the amount of
collateral blood flow.
4. Answer: B. Bleeding.
B: A patient taking tPA should be monitored for bleeding.
A: Allergic reaction is not a side effect of tPA.
C: Severe vomiting is not a side effect of tPA.
D: A second stroke is not a side effect of tPA.
5. Answer: D. Small artery thrombotic.

D: Small artery thrombotic is the most common type of origin for strokes.
A: Cardiogenic emboli is not the most common type of origin for strokes.
B: Cryptogenic is not the most common type of origin for strokes.
C: Large artery thrombotic is not the most common type of origin for strokes.
See Also
Posts related to Cerebrovascular Accident (Stroke):
8+ Cerebrovascular Accident (Stroke) Nursing Care Plans
Drugs Affecting Coagulation
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Medical-Surgical Nursing
Cerebrovascular Accident, ineffective cerebral tissue perfusion, stroke
5 Things Nurses Should Be Doing To Get Promoted
Fluid Volume Excess Nursing Care Plan
Marianne Belleza, R.N.
Marianne is a staff nurse during the day and a Nurseslabs writer at night. She is a registered nurse
since 2015 and is currently working in a regional tertiary hospital and is finishing her Master's in
Nursing this June. As an outpatient department nurse, she is a seasoned nurse in providing health
teachings to her patients making her also an excellent study guide writer for student nurses.
Marianne is also a mom of a toddler going through the terrible twos and her free time is spent on
readin
Ischemic strokes are caused by a blockage, usually, a clot that blocks blood flow to the brain.
Hemorrhagic strokes are sudden bleeding in the brain such as when an artery bursts. This can be
caused by an aneurysm, high blood pressure, or trauma.
Transient ischemic attacks (TIA) which may be referred to as “mini-strokes” are blockages in the
brain that resolve before lasting damage occurs. A history of TIAs can increase the risk of a stroke in
the future.
The Nursing Process
Stroke patients often require monitoring by nurses who are NIHSS certified and in higher care
settings such as the ICU or step-down units. This is because stroke symptoms can change rapidly and
subtly and require critical thinking and prompt intervention to prevent deterioration.
Depending on the severity, strokes can leave the patient disabled requiring total care in feeding,
bathing, and turning. Long-term deficits can be debilitating and cause depression for the client and
their family. The nurse utilizes compassionate care and alternative communication techniques to
keep the patient safe while managing their physical and psychosocial needs.
Nursing Care Plans Related to Cerebrovascular Accident (CVA) or Stroke
Ineffective Cerebral Tissue Perfusion Care Plan
When blood is blocked from the brain it does not receive necessary oxygen. If blood flow is not
restored promptly this will result in tissue death.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
Interruption of blood flow to the brain
Thrombus formation
Artery occlusion
Cerebral edema
Hemorrhage
As evidenced by:
Altered mental status
Blurred vision
Slurred speech
Extremity weakness
Expected Outcomes:
Patient will recognize symptoms of a stroke and seek immediate medical attention
Patient will display improved cerebral perfusion as evidenced by vital signs within ordered
parameters
Patient will display improvement in stroke deficits such as slurred speech, weakness, and swallowing
ability by discharge
Ineffective Cerebral Tissue Perfusion Assessment
1. Determine baseline presentation.
When assessing for a possible stroke it is vital to know the last time the client was “well” or at their
baseline level of functioning before exhibiting symptoms. Certain interventions (thrombolytics) can
only be administered within a 4-hour timeframe of when symptoms started. The nurse can also use
this information when performing follow-up assessments to determine improvement or
deterioration.
2. Perform neurological assessments.
The nurse will perform stroke scale assessments as directed by their facility. These frequent
assessments monitor LOC, visual changes, facial movement, motor coordination, sensory changes,
and speech or language deficits.
3. Obtain a CT scan or MRI of the brain.
These are the most important diagnostic tests to confirm or rule out a stroke. They also show
whether a stroke is hemorrhagic or ischemic which will further determine treatment.
Ineffective Cerebral Tissue Perfusion Interventions
1. Maintain blood pressure.
To maintain cerebral perfusion, blood pressure is kept elevated. For ischemic strokes, the blood
pressure may be allowed as high as 220 systolic (unless receiving thrombolytic therapy) and no lower
than 140 systolic for a hemorrhagic stroke. Specific parameters will be ordered by the provider.
2. Administer thrombolytics.
Thrombolytics are administered to dissolve clots in an ischemic stroke. They should never be
administered for a hemorrhagic stroke as this will cause fatal bleeding. Also, thrombolytics must be
administered within 4 hours of the development of stroke symptoms to be effective.
3. Educate on risk factors of strokes.
If the patient only experiences a TIA or does not suffer long-term deficits from a stroke, prevention
of a future stroke should be communicated. Risk factors include hypertension, heart disease,
diabetes, smoking, and stress. These are modifiable risk factors that the patient can work towards
changing through diet, exercise, and lifestyle behaviors.
4. Instruct on symptoms of a stroke using FAST.
“Time is tissue” in the instance of a stroke. The sooner symptoms are recognized, the quicker the
treatment, and less sustained damage to brain tissue. Patients and family members should be
instructed on the acronym F.A.S.T which stands for Facial drooping, Arm weakness, Speech difficulty,
and Time (call 911).
Impaired Verbal Communication Care Plan
Cerebrovascular accidents often result in deficits in communication. Patients may struggle with
comprehending or expressing speech as well as a physical inability to produce meaningful speech.
Nursing Diagnosis: Impaired Verbal Communication
Related to:
Prolonged cerebral occlusion
Dysarthria (weakened muscles used for speech)
Aphasia (impaired ability to comprehend or produce language)
As evidenced by:
Slurred speech
Nonverbal
Difficulty forming words
Difficulty expressing thoughts

Slow to respond due to delayed comprehension
Extremity weakness or paralysis resulting in an inability to write or type
Expected Outcomes:
Patient will establish a form of communication to express their thoughts and needs
Patient will participate in speech therapy to improve communication
Patient will utilize resources and devices to support communication
Impaired Verbal Communication Assessment
1. Note type of aphasia.
Global aphasia is severe and affects the patient’s ability to produce and understand language.
Wernicke’s aphasia may cause the patient to speak in nonsensical sentences. Broca’s aphasia means
the patient may understand what is said to them and know what they want to say but have difficulty
getting the words out.
2. Observe how the patient communicates.
Patients may have their own unique way of communicating such as in gestures, signals, or sounds.
Family members can aid in teaching the nurse how the patient requests something.
Impaired Verbal Communication Interventions
1. Speak in short, direct sentences.
Always speak clearly, facing the patient so they can see your lips and expressions. Use direct
sentences as they may not be able to comprehend abstract thoughts. Short “yes” or “no” questions
may be easiest for the patient to comprehend.
2. Utilize alternative communication methods.
Use writing, drawing, and flashcards if these work for the patient. The nurse and patient may be able
to work out a system to communicate needs such as a thumbs up or down, eye blinking, or smiling if
they are nonverbal.
3. Encourage speech therapy.
Speech-language therapy is vital in improving communication. Aphasia can improve over time and
speech therapy can help the patient restore language abilities as well as instruct on devices and
technology to aid in communicating.
4. Encourage family participation.
Family involvement is crucial as both the patient and family learn to maneuver communication
changes. Family members should also participate in therapy sessions and learn specific techniques
that support clear communication.
Risk For Injury Care Plan
Depending on the area of the brain affected by the stroke, the patient may have spatial-perceptual
issues and impaired judgment. Along with deficits in swallowing, motor coordination, and
generalized weakness, safety is a priority.
Nursing Diagnosis: Risk For Injury
Related to:
Impaired judgment
Spatial-perceptual deficit
Weakness
Poor motor coordination
Poor balance
Poor concept of time
Impaired sensory awareness
Dysphagia
Inability to communicate
Hemiplegia
Short attention span
Impulsivity
Note: A risk for diagnosis is not evidenced by signs and symptoms as the problem has not yet
occurred and nursing interventions are directed at prevention.
Expected Outcomes:
Patient will remain free from falls
Patient will maintain intact skin integrity

Caregivers will support the patient and create a modified environment to keep the patient safe and
free from injury
Risk For Injury Assessment
Determine deficits related to the area of brain injury.
Depending on the area of the brain that is damaged by the stroke the patient may display specific
deficits. Right-brain strokes may result in difficulty in gauging the distance of an object making
driving and walking dangerous. Left-brain strokes are more likely to have impaired swallowing and
speech.
Assess sensory awareness.
An inability to recognize pain, heat, or sharp sensations places the patient at an increased risk of skin
breakdown and injury.
Note neglect or visual disturbances.
A stroke on one side of the brain may cause a lack of awareness in the opposite side of the body.
This can also affect the visual field. Hemianopia is a loss of half of the visual field which can be
dangerous in certain situations.
Risk For Injury Interventions
1. Use bed and chair alarms.
When patients suffer a right-brain stroke specifically, they may be more impulsive and deny or
minimize their deficits. This puts them at high risk for injury and falls. Keeping a bed alarm on at all
times and a chair alarm if they are sitting up will increase safety.
2. Assist with eating.
Patients with dysphagia will require special meals and thickened liquids. Ensure they are chewing
and swallowing adequately and are not displaying signs of possible aspiration such as pocketing
food, drooling, or coughing.
3. Teach to scan the environment.
If the patient has left or right-sided neglect or visual disturbances teach them to scan from left to
right. This can help them when moving in their environment but also assist with activities such as
reading.
4. Turn and assess skin frequently.

If the patient is paralyzed on one side and lacks sensation it is the nurse’s responsibility to maintain
their skin integrity. Turn every 2 hours, keep boney areas supported, maintain proper alignment of
extremities and ensure lines and tubes are not digging into the patient’s skin.
References and Sources
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized
Interventions, and Rationales (11th ed.). F. A. Davis Company.
NIH Stroke Scale. (n.d.). Know Stroke. Retrieved February 17, 2022, from
https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf
Pressman, P. (2021, February 23). How Blood Pressure Is Managed After an Ischemic Stroke.
Verywell Health. Retrieved February 17, 2022, from https://www.verywellhealth.com/blood-
pressure-ischemic-stroke-2488837
Saver, J. L., & Lutsep, H. L. (2021, May 5). Thrombolytic Therapy in Stroke: Ischemic Stroke and
Neurologic Deficits, Clinical Trials, Thrombolysis Guidelines. Medscape Reference. Retrieved
February 17, 2022, from https://emedicine.medscape.com/article/1160840-overview
Stroke | NHLBI, NIH. (2020, October 28). National Heart, Lung, and Blood Institute. Retrieved
February 17, 2022, from https://www.nhlbi.nih.gov/health-topics/stroke
Stroke-related eye conditions. (n.d.). RNIB. Retrieved February 17, 2022, from
https://www.rnib.org.uk/eye-health/eye-conditions/stroke-related-eye-conditions
Published on February 18, 2022
Photo of author
Maegan Wagner, BSN, RN, CCM
Maegan Wagner is registered nurse with over 10 years of healthcare experience. She earned her
BSN at Western Governors University. Her nursing career has led her through many different
specialties including inpatient acute care, hospice, home health, case management, travel nursing,
and telehealth, but her passion lies in educating through writing for other healthcare professionals
and the general public.
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© Definition
§ A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of brain
function resulting from Cerebral Vascular Accident (Ischemic Stroke) a disruption of the blood supply
to a part of the brain.
§ Ischemic strokes are categorized according to their cause: large artery thrombotic strokes (20%),
small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic
strokes (30%), and other (5%).
§ Cryptogenic strokes have no known cause, and other strokes result from causes such as illicit drug
use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.
§ The result is an interruption in the blood supply to the brain, causing temporary or permanent loss
of movement, thought, memory, speech, or sensation.
Risk Factors
Nonmodifable
§ Advanced age (older than 55 years)
§ Gender (Male)
§ Race (African American)
Modifable
Hypertension
§ Atrial fibrillation
§ Hyperlipidemia
§ Obesity
§ Smoking
§ Diabetes
§ Asymptomatic carotid stenosis and valvular heart disease (eg, endocarditis, prosthetic heart
valves)
§ Periodontal disease
Clinical Manifestations
General signs and symptoms include numbness or weakness of face, arm, or leg (especially on one
side of body); confusion or change in mental status; trouble speaking or understanding speech;
visual disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache.
Motor Loss
§ Hemiplegia, hemiparesis
§ Flaccid paralysis and loss of or decrease in the deep tendon reflexes (initial clinical feature)
followed by (after 48 hours) reappearance of deep reflexes and abnormally increased muscle tone
(spasticity)
Communication Loss
§ Dysarthria (difficulty speaking)
§ Dysphasia (impaired speech) or aphasia (loss of speech)
§ Apraxia (inability to perform a previously learned action)
Perceptual Disturbances and Sensory Loss
Visualperceptual dysfunctions (homonymous hemianopia [loss of half of the visual field])
§ Disturbances in visualspatial relations (perceiving the relation of two or more objects in spatial
areas), frequently seen in patients with right hemispheric damage
Sensory losses: slight impairment of touch or more severe with loss of proprioception; difficulty in
interrupting visual, tactile, and auditory stimuli
Impaired Cognitive and Psychological Effects
§ Frontal lobe damage: Learning capacity, memory, or other higher cortical intellectual functions
may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in
comprehension, forgetfulness, and lack of motivation.
§ Depression, other psychological problems: emotional lability, hostility, frustration, resentment,

and lack of cooperation.
Assessment and Diagnostic Methods
History and complete physical and neurologic examination
§ Noncontrast CT scan
§ 12lead ECG and carotid ultrasound
§ CT angiography or MRI and angiography
§ Transcranial Doppler flow studies
§ Transthoracic or transesophageal echocardiography
§ Xenonenhanced CT scan
§ Single photon emission CT (SPECT) scan
Prevention
§ Help patients alter risk factors for stroke; encourage patient to quit smoking, maintain a healthy
weight, follow a healthy diet (including modest alcohol consumption), and exercise daily.
§ Prepare and support patient through carotid endarterectomy.
Administer anticoagulant agents as prescribed (eg, lowdose aspirin therapy).
Medical Management
§ Recombinant tissue plasminogen activator (tPA), unless contraindicated; monitor for bleeding
§ Anticoagulation therapy
§ Management of increased intracranial pressure (ICP): osmotic diuretics, maintain PaCO2 at 30 to

35 mm Hg, position to avoid hypoxia (elevate the head of bed to promote venous drainage and to
lower increased ICP)
§ Possible hemicraniectomy for increased ICP from brain edema in a very large stroke
§ Intubation with an endotracheal tube to establish a patent airway, if necessary
§ Continuous hemodynamic monitoring (the goals for blood pressure remain controversial for a
patient who has not received thrombolytic therapy; antihypertensive treatment may be withheld
unless the systolic blood pressure exceeds mm Hg or the diastolic blood pressure exceeds 120 mm
Hg) Neurologic assessment to determine if the stroke is evolving and if other acute complications are
developing
Management of Complications
§ Decreased cerebral blood flow: Pulmonary care, maintenance of a patent airway, and
administration of supplemental oxygen as needed.
§ Monitor for UTIs, cardiac dysrhythmias, and complications of immobility.
Nursing Assessment
During Acute Phase (1 to 3 days)
Weigh patient (used to determine medication dosages), and maintain a neurologic flow sheet to
reflect the following nursing assessment parameters:
§ Change in level of consciousness or responsiveness, ability to speak, and orientation

Presence or absence of voluntary or involuntary movements of the extremities: muscle tone, body
posture, and head position
§ Stiffness or flaccidity of the neck
§ Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position
§ Color of face and extremities; temperature and moisture of skin
§ Quality and rates of pulse and respiration; ABGs, body temperature, and arterial pressure
§ Volume of fluids ingested or administered and volume of urine excreted per 24 hours
§ Signs of bleeding
§ Blood pressure maintained within normal limits
Postacute Phase
Assess the following functions:
§ Mental status (memory, attention span, perception, orientation, affect, speech/language).
§ Sensation and perception (usually the patient
has decreased awareness of pain and temperature).
§ Motor control (upper and lower extremity movement); swallowing ability, nutritional and
hydration status, skin integrity, activity tolerance, and bowel and bladder function.
§ Continue focusing nursing assessment on impairment of function in patient’s daily activities.
Diagnosis
Nursing Diagnoses
§ Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and
brain injury
§ Acute pain related to hemiplegia and disuse
§ Deficient selfcare (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke
sequelae
§ Disturbed sensory perception (kinesthetic, tactile, or visual) related to altered sensory reception,
transmission, and/or integration
§ Impaired swallowing
§ Impaired urinary elimination related to flaccid bladder, detrusor instability, confusion, or difficulty
in communicating
§ Disturbed thought processes related to brain damage

§ Impaired verbal communication related to brain damage
§ Risk for impaired skin integrity related to hemiparesis or hemiplegia, decreased mobility
§ Interrupted family processes related to catastrophic illness and caregiving burdens
§ Sexual dysfunction related to neurologic deficits or fear of failure
Collaborative Problems/Potential Complications
§ Decreased cerebral blood flow due to increased ICP; inadequate oxygen delivery to the brain;
pneumonia.
Planning and Goals
The major goals for the patient (and family) may include improved mobility, avoidance of shoulder
pain, achievement of selfcare, relief of sensory and perceptual deprivation, prevention of aspiration,
continence of bowel and bladder, improved thought processes, achieving a form of communication,
maintaining skin integrity, restored family functioning, improved sexual function, and absence of
complications. Goals are affected by knowledge of what the patient was like before the stroke.
§ Position to prevent contractures; use measures to relieve pressure, assist in maintaining good
body alignment, and prevent compressive neuropathies.
§ Apply a splint at night to prevent flexion of affected extremity.
§ Prevent adduction of the affected shoulder with a pillow placed in the axilla.
§ Elevate affected arm to prevent edema and fibrosis.
§ Position fingers so that they are barely flexed; place hand in slight supination. If upper extremity
§ Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times
a day.
§ Provide full range of motion four or five times a day to maintain joint mobility, regain motor
control, prevent contractures in the paralyzed extremity, prevent further deterioration of the
neuromuscular system, and enhance circulation. If tightness occurs in any area, perform
rangeofmotion exercises more frequently.
§ Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis
and pulmonary embolus.
§ Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (eg,
§ Supervise and support patient during exercises; plan frequent short periods of exercise, not longer
periods; encourage patient to exercise unaffected side at intervals throughout the day.
§ Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is
§ Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt
table if needed).
§ Begin walking as soon as standing balance is achieved (use parallel bars and have wheelchair
§ Keep training periods for ambulation short and frequent.
NURSING ALERT: Initiate a full rehabilitation program even for elderly patients.
§ Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder.
§ Use proper patient movement and positioning (eg, flaccid arm on a table or pillows when patient
is seated, use of sling when ambulating).
§ Rangeofmotion exercises are beneficial, but avoid overstrenuous arm movements.
§ Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as
indicated.
Enhancing Self Care
§ Encourage personal hygiene activities as soon as the patient can sit up; select suitable selfcare
§ Help patient to set realistic goals; add a new task daily.
§ As a first step, encourage patient to carry out all selfcare activities on the unaffected side.
§ Make sure patient does not neglect affected side; provide assistive devices as indicated.
§ Improve morale by making sure patient is fully dressed during ambulatory activities.
§ Assist with dressing activities (eg, clothing with Velcro closures; put garment on the affected side
§ Provide emotional support and encouragement to prevent fatigue and discouragement.
Managing Sensory Perceptual Difficulties

§ Approach patient with a decreased field of vision on the side where visual perception is intact;
place all visual stimuli on this side.
§ Teach patient to turn and look in the direction of the defective visual field to compensate for the
§ Increase natural or artificial lighting in the room; provide eyeglasses to improve vision.
§ Remind patient with hemianopsia of the other side of the body; place extremities so that patient
can see them.
§ Observe patient for paroxysms of coughing, food dribbling out or pooling in one side of the
mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
§ Consult with speech therapist to evaluate gag reflexes; assist in teaching alternate swallowing
§ Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated.
§ Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check
§ Perform intermittent sterile catheterization during period of loss of sphincter control.
§ Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
§ Assist the male patient to an upright posture for voiding.
§ Provide highfiber diet and adequate fluid intake (2 to 3 L/day), unless contraindicated.
§ Establish a regular time (after breakfast) for toileting.
§ Reinforce structured training program using cognitiveperceptual retraining, visual imagery, reality
§ Support patient: Observe performance and progress, give positive feedback, convey an attitude of
§ Reinforce the individually tailored program.

§ Jointly establish goals, with patient taking an active part.
§ Make the atmosphere conducive to communication, remaining sensitive to patient’s reactions and
needs and responding to them in an appropriate manner; treat patient as an adult.
§ Provide strong emotional support and understanding to allay anxiety; avoid completing patient’s
sentences.
§ Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes
§ Maintain patient’s attention when talking with patient, speak slowly, and give one instruction at a
time; allow patient time to process.
§ Talk to aphasic patients when providing care activities to provide social contact.
§ Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body
parts.
§ Employ pressurerelieving devices; continue regular turning and positioning (every 2 hours
§ Keep skin clean and dry, gently massage healthy dry skin, and maintain adequate nutrition.
§ Provide counseling and support to family.
§ Involve others in patient’s care; teach stress management techniques and maintenance of
personal health for family coping.
§ Give family information about the expected outcome of the stroke, and counsel them to avoid
doing things for patient that he or she can do.
§ Develop attainable goals for patient at home by involving the total health care team, patient, and
family.
§ Encourage everyone to approach patient with a supportive and optimistic attitude, focusing on
abilities that remain; explain to family that emotional lability usually improveswith time.
§ Perform indepth assessment to determine sexual history before and after the stroke.
§ Interventions for patient and partner focus on providing relevant information, education,
§ of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and
a means of sexual expression and satisfaction.
Teaching Points
§ Teach patients about the “act FAST” Campaign
§ Teach patient to resume as much selfcare as possible; provide assistive devices as indicated.
§ Have occupational therapist make a home assessment and recommendations to help patient
§ Coordinate care provided by numerous health care professionals; help family plan aspects of care.
§ Advise family that patient may tire easily, become irritable and upset by small events, and show
less interest in daily events.
§ Make referral for home speech therapy. Encourage family involvement. Provide family with
§ Discuss patient’s depression with physician for possible antidepressant therapy.
§ Encourage patient to attend communitybased stroke clubs to give a feeling of belonging and
fellowship with others.
§ Encourage patient to continue with hobbies, recreational and leisure interests, and contact with
§ Encourage family to support patient and give positive reinforcement.
§ Remind spouse and family to attend to personal health and wellbeing.
Evaluation
Expected Patient Outcomes
§ Achieves improved mobility.
§ Has no complaints of pain.
§ Achieves selfcare; performs hygiene care; uses adaptive equipment.
§ Demonstrates techniques to compensate for altered sensory reception, such as turning the head
to see people or objects.
§ Demonstrates safe swallowing.
§ Achieves normal bowel and bladder elimination.
§ Participates in cognitive improvement program.
§ Demonstrates improved communication.
§ Maintains intact skin without breakdown.
§ Family members demonstrate a positive attitude and coping mechanisms.
§ Develops alternative approaches to sexual expression.

Nursing Care Plan
Nursing Diagnosis
§ Ineffective Cerebral Tissue Perfusion
May be related to
§ Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vasospasm, 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
Desired Outcomes
§ Maintain usual/improved level of consciousness, cognition, and motor/sensory function.
§ Demonstrate stable vital signs and absence of signs of increased ICP.
§ Display no further deterioration/recurrence of deficits
§ Assess factors related to individual situation for decreased cerebral perfusion and potential for
increased ICP.
§ Rationale: Assessment will determine and influence the choice of interventions. Deterioration in
neurological signs or failure to improve after initial insult may reflect decreased intracranial adaptive
capacity requiring patient to be transferred to critical area for monitoring of ICP, other therapies. If
the stroke is evolving, patient can deteriorate quickly and require repeated assessment and
progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and
treatment is geared toward rehabilitation and preventing recurrence.
§ Closely assess and monitor neurological status frequently and compare with baseline.
§ Rationale: Assesses trends in level of consciousness (LOC) and potential for increased ICP and is
useful in determining location, extent, and progression of damage. May also reveal presence of TIA,
which may warn of impending thrombotic CVA.
Monitor vital signs:
§ changes in blood pressure, compare BP readings in both arms.
§ Rationale: Fluctuations in pressure may occur because of cerebral injury in vasomotor area of the
brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may
occur because of shock (circulatory collapse). Increased ICPmay occur because of tissue edema or
clot formation. Subclavian artery blockage may be revealed by difference in pressure readings
between arms.
§ Heart rate and rhythm, assess for murmurs.
§ Rationale: Changes in rate, especially bradycardia, can occur because of the brain damage.
Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (stroke
after MI or from valve dysfunction).
§ Respirations, noting patterns and rhythm (periods of apnea after hyperventilation), Cheyne-Stokes
respiration.
§ Rationale: Irregularities can suggest location of cerebral insult or increasing ICP and need for
further intervention, including possible respiratory support.
§ Evaluate pupils, noting size, shape, equality, light reactivity.
§ Rationale: Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in
determining whether the brain stem is intact. Pupil size and equality is determined by balance
between parasympathetic and sympathetic innervation. Response to light reflects combined
function of the optic (II) and oculomotor (III) cranial nerves.
§ Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.
§ Rationale: Specific visual alterations reflect area of brain involved, indicate safety concerns, and
influence choice of interventions.
§ Assess higher functions, including speech, if patient is alert.
§ Rationale: Changes in cognition and speech content are an indicator of location and degree of
cerebral involvement and may indicate deterioration or increased ICP.
§ Position with head slightly elevated and in neutral position.
§ Rationale: Reduces arterial pressure by promoting venous drainage and may improve cerebral
perfusion.
§ Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster
nursing interventions and provide rest periods between care activities. Limit duration of procedures.
§ Rationale: Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest
and quiet may be needed to prevent rebleeding in the case of hemorrhage.
§ Prevent straining at stool, holding breath.
§ Rationale: Valsalva maneuver increases ICP and potentiates risk of rebleeding.
§ Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity.
§ Rationale: Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may

reflect increased ICP or cerebral injury, requiring further evaluation and intervention.
§ Administer supplemental oxygen as indicated.
§ Rationale: Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure
or edema formation.
Administer medications as indicated:
§ Alteplase (Activase), t-PA;
§ Rationale: Thrombolytic agents are useful in dissolving clot when started within 3 hr of initial
symptoms. Thirty percent are likely to recover with little or no disability. Treatment is based on
trying to limit the size of the infarct, and use requires close monitoring for signs of intracranial
hemorrhage. Note: These agents are contraindicated in cranial hemorrhage as diagnosed by CT scan.
§ Anticoagulants: warfarin sodium (Coumadin), low-molecular-weight heparin (Lovenox);
§ Rationale: May be used to improve cerebral blood flow and prevent further clotting when
embolism and/or thrombosis is the problem.
§ Antiplatelet agents: aspirin (ASA), dipyridamole (Persantine), ticlopidine (Ticlid);
§ Rationale: Contraindicated in hypertensive patients because of increased risk of hemorrhage.
§ Antifibrinolytics: aminocaproic acid (Amicar);
§ Rationale: Used with caution in hemorrhagic disorder to prevent lysis of formed clots and
subsequent rebleeding.
§ Antihypertensives
§ Rationale: Chronic hypertension requires cautious treatment because aggressive management

increases the risk of extension of tissue damage.
§ Peripheral vasodilators: cyclandelate (Cyclospasmol), papaverine (Pavabid), isoxsuprine

(Vasodilan).
§ Rationale: Transient hypertension often occurs during acute stroke and resolves often without
therapeutic intervention.Used to improve collateral circulation or decrease vasospasm.
§ Steroids: dexamethasone (Decadron).
§ Rationale: Use is controversial in control of cerebral edema.
§ Neuroprotective agents: calcium channel blockers, excitatory amino acid inhibitors, gangliosides.
§ Rationale: These agents are being researched as a means to protect the brain by interrupting the
destructive cascade of biochemical events (influx of calcium into cells, release of excitatory
neurotransmitters, buildup of lactic acid) to limit ischemic injury.
§ Phenytoin (Dilantin), phenobarbital.
§ Rationale: May be used to control seizures and/or for sedative action. Note: Phenobarbital
enhances action of antiepileptics.
§ Stool softeners.
§ Rationale: Prevents straining during bowel movement and corresponding increase of ICP.
§ Prepare for surgery, as appropriate: endarterectomy, microvascular bypass, cerebral angioplasty.
§ Rationale: May be necessary to resolve situation, reduce neurological symptoms of recurrent

stroke.
§ Monitor laboratory studies as indicated: prothrombin time (PT) and/or activated partial
thromboplastin time (aPTT) time, Dilantin level.
§ Rationale: Provides information about drug effectiveness and/or therapeutic level.
Nursing Diagnosis
§ Impaired Physical Mobility
May be related to
§ Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic

paralysis
§ Perceptual/cognitive impairment
§ Inability to purposefully move within the physical environment; impaired coordination; limited
range of motion; decreased muscle strength/control
Desired Outcomes
§ Maintain/increase strength and function of affected or compensatory body part.
§ Maintain optimal position of function as evidenced by absence of contractures, foot drop.
§ Demonstrate techniques/behaviors that enable resumption of activities.
§ Maintain skin integrity.
§ Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale.
§ Rationale: Identifies strengths and deficiencies that may provide information regarding recovery.
Assists in choice of interventions, because different techniques are used for flaccid and spastic
paralysis.
§ Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on
affected side.
§ Rationale: Reduces risk of tissue injury. Affected side has poorer circulation and reduced sensation
and is more predisposed to skin breakdown.
§ Position in prone position once or twice a day if patient can tolerate.
§ Rationale: Helps maintain functional hip extension; however, may increase anxiety, especially
about ability to breathe.
§ Prop extremities in functional position; use footboard during the period of flaccid paralysis.
Maintain neutral position of head.
§ Rationale: Prevents contractures and footdrop and facilitates use when 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.
§ Rationale: During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and
shoulder-hand syndrome.
§ Evaluate need for positional aids and/or splints during spastic paralysis:
§ Rationale: Flexion contractures occur because flexor muscles are stronger than extensors.
§ Place pillow under axilla to abduct arm
§ Rationale: Prevents adduction of shoulder and flexion of elbow.
§ Elevate arm and hand
§ Rationale: Promotes venous return and helps prevent edema formation.
§ Place hard hand-rolls in the palm with fingers and thumb opposed.
§ Rationale: Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in
a functional position.
§ Place knee and hop in extended position;
§ Rationale: Maintains functional position.
§ Maintain leg in neutral position with a trochanter roll;
§ Rationale: Prevents external hip rotation.
§ Discontinue use of footboard, when appropriate.
§ Rationale: 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.
§ Rationale: 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.
§ Rationale: Pressure points over bony prominences are most at risk for decreased perfusion.
Circulatory stimulation and padding help prevent skin breakdown and decubitus development.
§ Begin active or 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.
§ Rationale: Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces
risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive
stimulation can predispose to rebleeding.
§ Assist patient with exercise and perform ROM exercises for both the affected and unaffected
sides. Teach and encourage patient to use his unaffected side to exercise his affected side.
§ Assist patient to develop sitting balance by raising head of bed, assist to sit on edge of bed, having
patient to use the strong arm to support body weight and move using the strong leg. Assist to
develop standing balance by putting flat walking shoes, support patient’s lower back with hands
while positioning own knees outside patient’s knees, assist in using parallel bars.
§ Rationale:Aids in retraining neuronal pathways, enhancing proprioception and motor response.
§ Get patient up in chair as soon as vital signs are stable, except following cerebral hemorrhage.
§ Rationale:Helps stabilize BP (by restoring vasomotor tone), promotes maintenance of extremities

in a functional position and emptying of bladder, reducing risk of urinary stones and infections from
stasis. Note: If stroke is not completed, activity increases risk of additional bleed.
§ Pad chair seat with foam or water-filled cushion, and assist patient to shift weight at frequent
intervals.
§ Rationale: To prevent pressure on the coccyx and skin breakdown.
§ Set goals with patient and SO for participation in activities and position changes.
§ Rationale: Promotes sense of expectation of improvement, and provides some sense of control
and independence.
§ Encourage patient to assist with movement and exercises using unaffected extremity to support
and move weaker side.
§ Rationale: 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.
§ Provide egg-crate mattress, water bed, flotation device, or specialized beds, as indicated.
§ Rationale: Promotes even weight distribution, decreasing pressure on bony points and helping to
prevent skin breakdown and 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.
§ Position the patient and align his extremities correctly. Use high-top sneakers to prevent footdrop
and contracture and convoluted foam, flotation, or pulsating mattresses or sheepskin.
§ Rationale: These are measures to prevent pressure ulcers.
Nursing Diagnosis
§ 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
§ 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
Desired Outcomes
§ Indicate an understanding of the communication problems.
§ Establish method of communication in which needs can be expressed.
§ Use resources appropriately.
§ Assess extent of dysfunction: patient cannot understand words or has trouble speaking or making
self understood. Differentiate aphasia from dysarthria.
§ Rationale: Helps determine area and degree of brain involvement and difficulty patient has with
any or all steps of the communication process. Patient may have receptive aphasia or damage to the
Wernicke’s speech area which is characterized by difficulty of understanding spoken words. He may
also have expressive aphasia or damage to the Broca’s speech areas, which is difficulty in speaking
words correctly, or may experience both. Choice of interventions depends on type of impairment.
Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or
motor components (inability to comprehend written and/or spoken words or to write, make signs,
speak). A dysarthric person can understand, read, and write language but has difficulty forming and
pronouncing words because of weakness and paralysis of oral musculature. Patient may lose ability
to monitor verbal output and be unaware that communication is not sensible.
§ Listen for errors in conversation and provide feedback.
§ Rationale: Feedback helps patient realize why caregivers are not understanding or responding
appropriately and provides opportunity to clarify meaning.
§ Ask patient to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat
simple words or sentences;
§ Rationale: Tests for receptive aphasia.
§ Point to objects and ask patient to name them.
§ Rationale: Tests for expressive aphasia. Patient may recognize item but not be able to name it.
§ Have patient produce simple sounds (“Dog,” “meow,” “Shh”).
§ Rationale: Identifies dysarthria, because motor components of speech (tongue, lip movement,
breath control) can affect articulation and may or may not be accompanied by expressive aphasia.
§ Ask patient to write his name and a short sentence. If unable to write, have patient read a short
sentence.
§ Rationale: Tests for writing disability (agraphia) and deficits in reading comprehension (alexia),
which are also part of receptive and expressive aphasia.
§ Write a notice at the nurses’ station and patient’s room about speech impairment. Provide a
special call bell that can be activated by minimal pressure if necessary.
§ Rationale: Allays anxiety related to inability to communicate and fear that needs will not be met
promptly.
§ Provide alternative methods of communication: writing, pictures.
§ Rationale: Provides communication needs of patient based on individual situation and underlying
deficit.
§ Anticipate and provide for patient’s needs.
§ Rationale: Helpful in decreasing frustration when dependent on others and unable to

communication desires.
§ Talk directly to patient, speaking slowly and distinctly. Phrase questions to be answered simply by
yes or no. Progress in complexity as patient responds.
§ Rationale: Reduces confusion and allays 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 word and idea association.
§ Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Avoid
pressing for a response.
§ Rationale: 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 (garbled speech, obscenities).
§ Encourage SO/visitors to persist in efforts to communicate with patient: reading mail, discussing
family happenings even if patient is unable to respond appropriately.
§ Rationale: 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., weather, family, hobbies, jobs.
§ Rationale: Promotes meaningful conversation and provides opportunity to practice skills.
§ Respect patient’s preinjury capabilities; avoid “speaking down” to patient or making patronizing
remarks.
§ Rationale: Enables patient to feel esteemed, because intellectual abilities often remain intact.
§ Consult and refer patient to speech therapist.
§ Rationale: Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to
identify deficits/therapy needs.
Nursing Diagnosis
§ Disturbed Sensory Perception
May be related to
§ Altered sensory reception, transmission, integration (neurological trauma or deficit)
§ Psychological stress (narrowed perceptual fields caused by anxiety)
§ 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
Desired Outcomes
§ Regain/maintain usual level of consciousness and perceptual functioning.
§ Acknowledge changes in ability and presence of residual involvement.
§ Demonstrate behaviors to compensate for/overcome deficits.
§ Review pathology of individual condition.
§ Rationale: Awareness on the type and areas of involvement aid in assessing specific deficit and
planning of care.
§ Observe behavioral responses: crying, inappropriate affect, agitation, hostility, agitation,

hallucination.
§ Rationale: Individual responses are variable, but commonalities such as emotional lability, lowered
frustration threshold, apathy, and impulsiveness may complicate care.
§ Establish and maintain communication with the patient. Set up a simple method of
communicating basic needs. Remember to phrase your questions so he’ll be able to answer using
this system. Repeat yourself quietly and calmly and use gestures when necessary to help in
understanding.
§ Rationale: Note: even an unresponsive patient may be able to hear, so don’t say anything in his
presence you wouldn’t want him to hear and remember.
§ Eliminate extraneous noise and stimuli as necessary.
§ Rationale: Reduces anxiety and exaggerated emotional responses and confusion associated with
sensory overload.
§ Speak in calm, comforting, quiet voice, using short sentences. Maintain eye contact.
§ Rationale: Patient may have limited attention span or problems with comprehension. These
measures can help patient attend to communication.
§ Ascertain patient’s perceptions. Reorient patient frequently to environment, staff, procedures.
§ Rationale: 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
and/or vertical planes), presence of diplopia (double vision).
§ Rationale: Presence of visual disorders can negatively affect patient’s ability to perceive
environment and relearn motor skills and increases risk of accident and injury.
§ Approach patient from visually intact side. Leave light on; position objects to take advantage of
intact visual fields. Patch affected eye if indicated.
§ Rationale: Helps the patient to recognize the presence of persons or objects and may help with
depth perception problems. This also prevents patient from being startled. Patching the eye may
decrease sensory confusion of double vision.
§ Assess sensory awareness: dull from sharp, hot from cold, position of body parts, joint sense.
§ Rationale: Diminished sensory awareness and impairment of kinesthetic sense negatively affects
balance and positioning and appropriateness of movement, which interferes with ambulation,
increasing risk of trauma.
§ Stimulate sense of touch. Give patient objects to touch, and hold. Have patient practice touching
walls boundaries.
§ Rationale: 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.
§ Rationale: Promotes patient safety, reducing risk of injury.
§ Note inattention to body parts, segments of environment, lack of recognition of familiar

objects/persons.
§ Rationale: Agnosia, the loss of comprehension of auditory, visual, or other sensations, may lead
result to unilateral neglect, inability to recognize environmental cues, 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: sensory stimulation to affected side, exercises that bring
affected side across midline, reminding person to dress/care for affected (“blind”) side.
§ Rationale: Use of visual and tactile stimuli assists in reintegration of affected side and allows
patient to experience forgotten sensations of normal movement patterns.
Nursing Diagnosis
§ Ineffective Coping
May be related to
§ Situational crises, vulnerability, cognitive perceptual changes
§ 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
Desired Outcomes
§ Verbalize acceptance of self in situation.
§ Talk/communicate with SO about situation and changes that have occurred.
§ Verbalize awareness of own coping abilities.
§ Meet psychological needs as evidenced by appropriate expression of feelings, identification of

options, and use of resources.
§ Assess extent of altered perception and related degree of disability. Determine Functional
Independence Measure score.
§ Rationale: Determination of individual factors aids in developing plan of care/choice of

interventions and discharge expectations.
§ Identify meaning of the dysfunction and change to patient. Note ability to understand events,
provide realistic appraisal of the situation.
§ Rationale: Independence is highly valued in American culture but is not as significant in some
cultures. Some patients accept and manage altered function effectively with little adjustment,
whereas others may have considerable difficulty recognizing and adjust to deficits. In order to
provide meaningful support and appropriate problem-solving, healthcare providers need to
understand the meaning of the stroke/limitations to patient.
§ Determine outside stressors: family, work, future healthcare needs.
§ Rationale: Helps identify specific needs, provides opportunity to offer information and begin
problem-solving. Consideration of social factors, in addition to functional status, is important in
determining appropriate discharge destination.
§ Provide psychological support and set realistic short-term goals. Involve the patient’s SO in plan of
care when possible and explain his deficits and strengths.
§ Rationale: To increase the patient’s sense of confidence and can help in compliance to therapeutic
regimen.
§ Encourage patient to express feelings, including hostility or anger, denial, depression, sense of
disconnectedness.
§ Rationale: Demonstrates acceptance of 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.”
§ Rationale: Suggests rejection of body part and 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 (weak,
affected, right-left) that incorporate that side as part of the whole body.
§ Rationale: 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 of support systems.
§ Rationale: Provides opportunity to use behaviors previously effective, build on past successes, and
mobilize resources.
§ Emphasize small gains either in recovery of function or independence.
§ Rationale: Consolidates gains, helps reduce feelings of anger and helplessness, and conveys sense
of progress.
§ Support behaviors and efforts such as increased interest/participation in rehabilitation activities.
§ Rationale: Suggest possible adaptation to changes and understanding about own role in future
lifestyle.
§ Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope,
lethargy, withdrawal.
§ Rationale: May indicate onset of depression (common after effect of stroke), which may require
further evaluation and intervention.
§ Refer for neuropsychological evaluation and/or counseling if indicated.
§ Rationale: 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.
Nursing Diagnosis
§ Self-Care Deficit
May be related to
§ Neuromuscular impairment, decreased strength and endurance, loss of muscle

control/coordination
§ Pain/discomfort
§ Depression
§ 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
Desired Outcomes
§ Demonstrate techniques/lifestyle changes to meet self-care needs.
§ Perform self-care activities within level of own ability.
§ Identify personal/community resources that can provide assistance as needed.
§ Assess abilities and level of deficit (0–4 scale) for performing ADLs.
§ Rationale: Aids in planning for meeting individual needs.
§ Avoid doing things for patient that patient can do for self, but provide assistance as necessary.
§ Rationale: To maintain self-esteem and promote recovery, it is important for the patient to do as
much as possible for self. These patients may become fearful and independent, although assistance
is helpful in preventing frustration.
§ Be aware of impulsive actions suggestive of impaired judgment.
§ Rationale: May indicate need for additional interventions and supervision to promote patient
safety.
§ Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks. Don’t rush
the patient.
§ Rationale: Patients need empathy and to know caregivers will be consistent in their assistance.
§ Provide positive feedback for efforts and accomplishments.
§ Rationale: Enhances sense of self-worth, promotes independence, and encourages patient to

continue endeavors.
§ Create plan for visual deficits that are present: 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.
§ Rationale: 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: extensions with hooks for picking things up from the floor, toilet risers,
long-handled brushes, drinking straw, leg bag for catheter, shower chair. Encourage good grooming
and makeup habits.
§ Rationale: To enable the patient to manage for self, enhancing independence and self-esteem,
reduce reliance on others for meeting own needs, and enables the patient to be more socially active.
§ Encourage SO to allow patient to do as much as possible for self.
§ Rationale: Reestablishes sense of independence and fosters self-worth and enhances

rehabilitation process. Note: This may be very difficult and frustrating for the 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 periodic intervals for voiding if appropriate.
§ Rationale: 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.
§ Rationale: Assists in development of retraining program (independence) and aids in preventing

constipation and impaction (long-term effects).
§ Teach the patient to comb hair, dress, and wash.
§ Rationale: To promote sense o f independence and self-esteem.
§ Refer patient to physical and occupational therapist.
§ Rationale: Rehabilitation helps to relearn skills that are lost when part of the brain is damaged. It
also teaches new ways of performing tasks to circumvent or compensate for any residual disabilities.
Risk for impaired skin integrity related to hemiparesis or hemiplegia, decreased mobility
§ Interrupted family processes related to catastrophic illness and caregiving burdens
§ Sexual dysfunction related to neurologic deficits or fear of failure
Collaborative Problems/Potential Complications
§ Decreased cerebral blood flow due to increased ICP; inadequate oxygen delivery to the brain;
pneumonia.
Planning and Goals
The major goals for the patient (and family) may include improved mobility, avoidance of shoulder
pain, achievement of selfcare, relief of sensory and perceptual deprivation, prevention of aspiration,
continence of bowel and bladder, improved thought processes, achieving a form of communication,
maintaining skin integrity, restored family functioning, improved sexual function, and absence of
complications. Goals are affected by knowledge of what the patient was like before the stroke.
§ Position to prevent contractures; use measures to relieve pressure, assist in maintaining good
body alignment, and prevent compressive neuropathies.
§ Apply a splint at night to prevent flexion of affected extremity.
§ Prevent adduction of the affected shoulder with a pillow placed in the axilla.
§ Elevate affected arm to prevent edema and fibrosis.
§ Position fingers so that they are barely flexed; place hand in slight supination. If upper extremity
§ Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times
a day.
§ Provide full range of motion four or five times a day to maintain joint mobility, regain motor
control, prevent contractures in the paralyzed extremity, prevent further deterioration of the
neuromuscular system, and enhance circulation. If tightness occurs in any area, perform
rangeofmotion exercises more frequently.
§ Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis
and pulmonary embolus.
§ Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (eg,
§ Supervise and support patient during exercises; plan frequent short periods of exercise, not longer
periods; encourage patient to exercise unaffected side at intervals throughout the day.
§ Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is
§ Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt
table if needed).
§ Begin walking as soon as standing balance is achieved (use parallel bars and have wheelchair
§ Keep training periods for ambulation short and frequent.
NURSING ALERT: Initiate a full rehabilitation program even for elderly patients.
§ Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder.
§ Use proper patient movement and positioning (eg, flaccid arm on a table or pillows when patient
is seated, use of sling when ambulating).
§ Rangeofmotion exercises are beneficial, but avoid overstrenuous arm movements.
§ Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as
indicated.
Enhancing Self Care
§ Encourage personal hygiene activities as soon as the patient can sit up; select suitable selfcare
§ Help patient to set realistic goals; add a new task daily.
§ As a first step, encourage patient to carry out all selfcare activities on the unaffected side.
§ Make sure patient does not neglect affected side; provide assistive devices as indicated.
§ Improve morale by making sure patient is fully dressed during ambulatory activities.
§ Assist with dressing activities (eg, clothing with Velcro closures; put garment on the affected side
§ Provide emotional support and encouragement to prevent fatigue and discouragement.
Managing Sensory Perceptual Difficulties
§ Approach patient with a decreased field of vision on the side where visual perception is intact;
place all visual stimuli on this side.
§ Teach patient to turn and look in the direction of the defective visual field to compensate for the
§ Increase natural or artificial lighting in the room; provide eyeglasses to improve vision.
§ Remind patient with hemianopsia of the other side of the body; place extremities so that patient
can see them.
§ Observe patient for paroxysms of coughing, food dribbling out or pooling in one side of the
mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
§ Consult with speech therapist to evaluate gag reflexes; assist in teaching alternate swallowing
§ Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated.
§ Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check
§ Perform intermittent sterile catheterization during period of loss of sphincter control.
§ Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
§ Assist the male patient to an upright posture for voiding.
§ Provide highfiber diet and adequate fluid intake (2 to 3 L/day), unless contraindicated.
§ Establish a regular time (after breakfast) for toileting.
§ Reinforce structured training program using cognitiveperceptual retraining, visual imagery, reality
§ Support patient: Observe performance and progress, give positive feedback, convey an attitude of
§ Reinforce the individually tailored program.
§ Jointly establish goals, with patient taking an active part.
§ Make the atmosphere conducive to communication, remaining sensitive to patient’s reactions and
needs and responding to them in an appropriate manner; treat patient as an adult.
§ Provide strong emotional support and understanding to allay anxiety; avoid completing patient’s
sentences.
§ Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes
§ Maintain patient’s attention when talking with patient, speak slowly, and give one instruction at a
time; allow patient time to process.
§ Talk to aphasic patients when providing care activities to provide social contact.

§ Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body
parts.
§ Employ pressurerelieving devices; continue regular turning and positioning (every 2 hours
§ Keep skin clean and dry, gently massage healthy dry skin, and maintain adequate nutrition.
§ Provide counseling and support to family.
§ Involve others in patient’s care; teach stress management techniques and maintenance of
personal health for family coping.
§ Give family information about the expected outcome of the stroke, and counsel them to avoid
doing things for patient that he or she can do.
§ Develop attainable goals for patient at home by involving the total health care team, patient, and
family.
§ Encourage everyone to approach patient with a supportive and optimistic attitude, focusing on
abilities that remain; explain to family that emotional lability usually improveswith time.
§ Perform indepth assessment to determine sexual history before and after the stroke.
§ Interventions for patient and partner focus on providing relevant information, education,
§ of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and
a means of sexual expression and satisfaction.
Teaching Points
§ Teach patients about the “act FAST” Campaign
§ Teach patient to resume as much selfcare as possible; provide assistive devices as indicated.
§ Have occupational therapist make a home assessment and recommendations to help patient
§ Coordinate care provided by numerous health care professionals; help family plan aspects of care.
§ Advise family that patient may tire easily, become irritable and upset by small events, and show
less interest in daily events.
§ Make referral for home speech therapy. Encourage family involvement. Provide family with
§ Discuss patient’s depression with physician for possible antidepressant therapy.

§ Encourage patient to attend communitybased stroke clubs to give a feeling of belonging and
fellowship with others.
§ Encourage patient to continue with hobbies, recreational and leisure interests, and contact with
§ Encourage family to support patient and give positive reinforcement.
§ Remind spouse and family to attend to personal health and wellbeing.
Evaluation
Expected Patient Outcomes
§ Achieves improved mobility.
§ Has no complaints of pain.
§ Achieves selfcare; performs hygiene care; uses adaptive equipment.
§ Demonstrates techniques to compensate for altered sensory reception, such as turning the head
to see people or objects.
§ Demonstrates safe swallowing.
§ Achieves normal bowel and bladder elimination.
§ Participates in cognitive improvement program.
§ Demonstrates improved communication.
§ Maintains intact skin without breakdown.
§ Family members demonstrate a positive attitude and coping mechanisms.
§ Develops alternative approaches to sexual expression.
Nursing Care Plan
Nursing Diagnosis
§ Ineffective Cerebral Tissue Perfusion
May be related to
§ Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vasospasm, cerebral edema
§ Altered level of consciousness; memory loss
§ Changes in motor/sensory responses; restlessness
§ Sensory, language, intellectual, and emotional deficits
§ Changes in vital signs

Desired Outcomes
§ Maintain usual/improved level of consciousness, cognition, and motor/sensory function.
§ Demonstrate stable vital signs and absence of signs of increased ICP.
§ Display no further deterioration/recurrence of deficits
§ Assess factors related to individual situation for decreased cerebral perfusion and potential for
increased ICP.
§ Rationale: Assessment will determine and influence the choice of interventions. Deterioration in
neurological signs or failure to improve after initial insult may reflect decreased intracranial adaptive
capacity requiring patient to be transferred to critical area for monitoring of ICP, other therapies. If
the stroke is evolving, patient can deteriorate quickly and require repeated assessment and
progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and
treatment is geared toward rehabilitation and preventing recurrence.
§ Closely assess and monitor neurological status frequently and compare with baseline.
§ Rationale: Assesses trends in level of consciousness (LOC) and potential for increased ICP and is
useful in determining location, extent, and progression of damage. May also reveal presence of TIA,
which may warn of impending thrombotic CVA.
Monitor vital signs:
§ changes in blood pressure, compare BP readings in both arms.
§ Rationale: Fluctuations in pressure may occur because of cerebral injury in vasomotor area of the
brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may
occur because of shock (circulatory collapse). Increased ICPmay occur because of tissue edema or
clot formation. Subclavian artery blockage may be revealed by difference in pressure readings
between arms.
§ Heart rate and rhythm, assess for murmurs.
§ Rationale: Changes in rate, especially bradycardia, can occur because of the brain damage.
Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (stroke
after MI or from valve dysfunction).
§ Respirations, noting patterns and rhythm (periods of apnea after hyperventilation), Cheyne-Stokes
respiration.
§ Rationale: Irregularities can suggest location of cerebral insult or increasing ICP and need for
further intervention, including possible respiratory support.
§ Evaluate pupils, noting size, shape, equality, light reactivity.
§ Rationale: Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in
determining whether the brain stem is intact. Pupil size and equality is determined by balance
between parasympathetic and sympathetic innervation. Response to light reflects combined
function of the optic (II) and oculomotor (III) cranial nerves.
§ Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.
§ Rationale: Specific visual alterations reflect area of brain involved, indicate safety concerns, and
influence choice of interventions.
§ Assess higher functions, including speech, if patient is alert.
§ Rationale: Changes in cognition and speech content are an indicator of location and degree of
cerebral involvement and may indicate deterioration or increased ICP.
§ Position with head slightly elevated and in neutral position.
§ Rationale: Reduces arterial pressure by promoting venous drainage and may improve cerebral
perfusion.
§ Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster
nursing interventions and provide rest periods between care activities. Limit duration of procedures.
§ Rationale: Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest
and quiet may be needed to prevent rebleeding in the case of hemorrhage.
§ Prevent straining at stool, holding breath.
§ Rationale: Valsalva maneuver increases ICP and potentiates risk of rebleeding.
§ Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity.
§ Rationale: Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may

reflect increased ICP or cerebral injury, requiring further evaluation and intervention.
§ Administer supplemental oxygen as indicated.
§ Rationale: Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure
or edema formation.
Administer medications as indicated:
§ Alteplase (Activase), t-PA;
§ Rationale: Thrombolytic agents are useful in dissolving clot when started within 3 hr of initial
symptoms. Thirty percent are likely to recover with little or no disability. Treatment is based on
trying to limit the size of the infarct, and use requires close monitoring for signs of intracranial
hemorrhage. Note: These agents are contraindicated in cranial hemorrhage as diagnosed by CT scan.
§ Anticoagulants: warfarin sodium (Coumadin), low-molecular-weight heparin (Lovenox);
§ Rationale: May be used to improve cerebral blood flow and prevent further clotting when
embolism and/or thrombosis is the problem.
§ Antiplatelet agents: aspirin (ASA), dipyridamole (Persantine), ticlopidine (Ticlid);
§ Rationale: Contraindicated in hypertensive patients because of increased risk of hemorrhage.
§ Antifibrinolytics: aminocaproic acid (Amicar);

§ Rationale: Used with caution in hemorrhagic disorder to prevent lysis of formed clots and
subsequent rebleeding.
§ Antihypertensives
§ Rationale: Chronic hypertension requires cautious treatment because aggressive management

increases the risk of extension of tissue damage.
§ Peripheral vasodilators: cyclandelate (Cyclospasmol), papaverine (Pavabid), isoxsuprine

(Vasodilan).
§ Rationale: Transient hypertension often occurs during acute stroke and resolves often without
therapeutic intervention.Used to improve collateral circulation or decrease vasospasm.
§ Steroids: dexamethasone (Decadron).
§ Rationale: Use is controversial in control of cerebral edema.
§ Neuroprotective agents: calcium channel blockers, excitatory amino acid inhibitors, gangliosides.
§ Rationale: These agents are being researched as a means to protect the brain by interrupting the
destructive cascade of biochemical events (influx of calcium into cells, release of excitatory
neurotransmitters, buildup of lactic acid) to limit ischemic injury.
§ Phenytoin (Dilantin), phenobarbital.
§ Rationale: May be used to control seizures and/or for sedative action. Note: Phenobarbital
enhances action of antiepileptics.
§ Stool softeners.
§ Rationale: Prevents straining during bowel movement and corresponding increase of ICP.
§ Prepare for surgery, as appropriate: endarterectomy, microvascular bypass, cerebral angioplasty.
§ Rationale: May be necessary to resolve situation, reduce neurological symptoms of recurrent

stroke.
§ Monitor laboratory studies as indicated: prothrombin time (PT) and/or activated partial
thromboplastin time (aPTT) time, Dilantin level.
§ Rationale: Provides information about drug effectiveness and/or therapeutic level.
Nursing Diagnosis
§ Impaired Physical Mobility
May be related to
§ Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic

paralysis
§ Inability to purposefully move within the physical environment; impaired coordination; limited
range of motion; decreased muscle strength/control
Desired Outcomes
§ Maintain/increase strength and function of affected or compensatory body part.
§ Maintain optimal position of function as evidenced by absence of contractures, foot drop.
§ Demonstrate techniques/behaviors that enable resumption of activities.
§ Maintain skin integrity.
§ Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale.
§ Rationale: Identifies strengths and deficiencies that may provide information regarding recovery.
Assists in choice of interventions, because different techniques are used for flaccid and spastic
paralysis.
§ Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on
affected side.
§ Rationale: Reduces risk of tissue injury. Affected side has poorer circulation and reduced sensation
and is more predisposed to skin breakdown.
§ Position in prone position once or twice a day if patient can tolerate.
§ Rationale: Helps maintain functional hip extension; however, may increase anxiety, especially
about ability to breathe.
§ Prop extremities in functional position; use footboard during the period of flaccid paralysis.
Maintain neutral position of head.
§ Rationale: Prevents contractures and footdrop and facilitates use when 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.
§ Rationale: During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and
shoulder-hand syndrome.
§ Evaluate need for positional aids and/or splints during spastic paralysis:
§ Rationale: Flexion contractures occur because flexor muscles are stronger than extensors.
§ Place pillow under axilla to abduct arm
§ Rationale: Prevents adduction of shoulder and flexion of elbow.
§ Elevate arm and hand
§ Rationale: Promotes venous return and helps prevent edema formation.
§ Place hard hand-rolls in the palm with fingers and thumb opposed.
§ Rationale: Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in
a functional position.
§ Place knee and hop in extended position;
§ Rationale: Maintains functional position.
§ Maintain leg in neutral position with a trochanter roll;
§ Rationale: Prevents external hip rotation.
§ Discontinue use of footboard, when appropriate.
§ Rationale: 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.
§ Rationale: 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.
§ Rationale: Pressure points over bony prominences are most at risk for decreased perfusion.
Circulatory stimulation and padding help prevent skin breakdown and decubitus development.
§ Begin active or 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.
§ Rationale: Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces
risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive
stimulation can predispose to rebleeding.
§ Assist patient with exercise and perform ROM exercises for both the affected and unaffected
sides. Teach and encourage patient to use his unaffected side to exercise his affected side.
§ Assist patient to develop sitting balance by raising head of bed, assist to sit on edge of bed, having
patient to use the strong arm to support body weight and move using the strong leg. Assist to
develop standing balance by putting flat walking shoes, support patient’s lower back with hands
while positioning own knees outside patient’s knees, assist in using parallel bars.
§ Rationale:Aids in retraining neuronal pathways, enhancing proprioception and motor response.
§ Get patient up in chair as soon as vital signs are stable, except following cerebral hemorrhage.
§ Rationale:Helps stabilize BP (by restoring vasomotor tone), promotes maintenance of extremities

in a functional position and emptying of bladder, reducing risk of urinary stones and infections from
stasis. Note: If stroke is not completed, activity increases risk of additional bleed.
§ Pad chair seat with foam or water-filled cushion, and assist patient to shift weight at frequent
intervals.
§ Rationale: To prevent pressure on the coccyx and skin breakdown.
§ Set goals with patient and SO for participation in activities and position changes.
§ Rationale: Promotes sense of expectation of improvement, and provides some sense of control
and independence.
§ Encourage patient to assist with movement and exercises using unaffected extremity to support
and move weaker side.
§ Rationale: 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.
§ Provide egg-crate mattress, water bed, flotation device, or specialized beds, as indicated.
§ Rationale: Promotes even weight distribution, decreasing pressure on bony points and helping to
prevent skin breakdown and 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.
§ Position the patient and align his extremities correctly. Use high-top sneakers to prevent footdrop
and contracture and convoluted foam, flotation, or pulsating mattresses or sheepskin.
§ Rationale: These are measures to prevent pressure ulcers.
Nursing Diagnosis
§ 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
§ 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
Desired Outcomes
§ Indicate an understanding of the communication problems.
§ Establish method of communication in which needs can be expressed.
§ Use resources appropriately.
§ Assess extent of dysfunction: patient cannot understand words or has trouble speaking or making
self understood. Differentiate aphasia from dysarthria.
§ Rationale: Helps determine area and degree of brain involvement and difficulty patient has with
any or all steps of the communication process. Patient may have receptive aphasia or damage to the
Wernicke’s speech area which is characterized by difficulty of understanding spoken words. He may
also have expressive aphasia or damage to the Broca’s speech areas, which is difficulty in speaking
words correctly, or may experience both. Choice of interventions depends on type of impairment.
Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or
motor components (inability to comprehend written and/or spoken words or to write, make signs,
speak). A dysarthric person can understand, read, and write language but has difficulty forming and
pronouncing words because of weakness and paralysis of oral musculature. Patient may lose ability
to monitor verbal output and be unaware that communication is not sensible.
§ Listen for errors in conversation and provide feedback.
§ Rationale: Feedback helps patient realize why caregivers are not understanding or responding
appropriately and provides opportunity to clarify meaning.
§ Ask patient to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat
simple words or sentences;
§ Rationale: Tests for receptive aphasia.
§ Point to objects and ask patient to name them.
§ Rationale: Tests for expressive aphasia. Patient may recognize item but not be able to name it.
§ Have patient produce simple sounds (“Dog,” “meow,” “Shh”).
§ Rationale: Identifies dysarthria, because motor components of speech (tongue, lip movement,
breath control) can affect articulation and may or may not be accompanied by expressive aphasia.
§ Ask patient to write his name and a short sentence. If unable to write, have patient read a short
sentence.
§ Rationale: Tests for writing disability (agraphia) and deficits in reading comprehension (alexia),
which are also part of receptive and expressive aphasia.
§ Write a notice at the nurses’ station and patient’s room about speech impairment. Provide a
special call bell that can be activated by minimal pressure if necessary.
§ Rationale: Allays anxiety related to inability to communicate and fear that needs will not be met
promptly.
§ Provide alternative methods of communication: writing, pictures.
§ Rationale: Provides communication needs of patient based on individual situation and underlying
deficit.
§ Anticipate and provide for patient’s needs.
§ Rationale: Helpful in decreasing frustration when dependent on others and unable to

communication desires.
§ Talk directly to patient, speaking slowly and distinctly. Phrase questions to be answered simply by
yes or no. Progress in complexity as patient responds.
§ Rationale: Reduces confusion and allays 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 word and idea association.
§ Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Avoid
pressing for a response.
§ Rationale: 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 (garbled speech, obscenities).
§ Encourage SO/visitors to persist in efforts to communicate with patient: reading mail, discussing
family happenings even if patient is unable to respond appropriately.
§ Rationale: 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., weather, family, hobbies, jobs.
§ Rationale: Promotes meaningful conversation and provides opportunity to practice skills.
§ Respect patient’s preinjury capabilities; avoid “speaking down” to patient or making patronizing
remarks.
§ Rationale: Enables patient to feel esteemed, because intellectual abilities often remain intact.
§ Consult and refer patient to speech therapist.
§ Rationale: Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to
identify deficits/therapy needs.
Nursing Diagnosis
§ Disturbed Sensory Perception
May be related to
§ Altered sensory reception, transmission, integration (neurological trauma or deficit)
§ Psychological stress (narrowed perceptual fields caused by anxiety)
§ 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
Desired Outcomes
§ Regain/maintain usual level of consciousness and perceptual functioning.
§ Acknowledge changes in ability and presence of residual involvement.
§ Demonstrate behaviors to compensate for/overcome deficits.
§ Review pathology of individual condition.
§ Rationale: Awareness on the type and areas of involvement aid in assessing specific deficit and
planning of care.
§ Observe behavioral responses: crying, inappropriate affect, agitation, hostility, agitation,

hallucination.
§ Rationale: Individual responses are variable, but commonalities such as emotional lability, lowered
frustration threshold, apathy, and impulsiveness may complicate care.
§ Establish and maintain communication with the patient. Set up a simple method of
communicating basic needs. Remember to phrase your questions so he’ll be able to answer using
this system. Repeat yourself quietly and calmly and use gestures when necessary to help in
understanding.
§ Rationale: Note: even an unresponsive patient may be able to hear, so don’t say anything in his
presence you wouldn’t want him to hear and remember.
§ Eliminate extraneous noise and stimuli as necessary.
§ Rationale: Reduces anxiety and exaggerated emotional responses and confusion associated with
sensory overload.
§ Speak in calm, comforting, quiet voice, using short sentences. Maintain eye contact.
§ Rationale: Patient may have limited attention span or problems with comprehension. These
measures can help patient attend to communication.
§ Ascertain patient’s perceptions. Reorient patient frequently to environment, staff, procedures.
§ Rationale: 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
and/or vertical planes), presence of diplopia (double vision).
§ Rationale: Presence of visual disorders can negatively affect patient’s ability to perceive
environment and relearn motor skills and increases risk of accident and injury.
§ Approach patient from visually intact side. Leave light on; position objects to take advantage of
intact visual fields. Patch affected eye if indicated.
§ Rationale: Helps the patient to recognize the presence of persons or objects and may help with
depth perception problems. This also prevents patient from being startled. Patching the eye may
decrease sensory confusion of double vision.
§ Assess sensory awareness: dull from sharp, hot from cold, position of body parts, joint sense.
§ Rationale: Diminished sensory awareness and impairment of kinesthetic sense negatively affects
balance and positioning and appropriateness of movement, which interferes with ambulation,
increasing risk of trauma.
§ Stimulate sense of touch. Give patient objects to touch, and hold. Have patient practice touching
walls boundaries.
§ Rationale: 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.
§ Rationale: Promotes patient safety, reducing risk of injury.
§ Note inattention to body parts, segments of environment, lack of recognition of familiar

objects/persons.
§ Rationale: Agnosia, the loss of comprehension of auditory, visual, or other sensations, may lead
result to unilateral neglect, inability to recognize environmental cues, 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: sensory stimulation to affected side, exercises that bring
affected side across midline, reminding person to dress/care for affected (“blind”) side.
§ Rationale: Use of visual and tactile stimuli assists in reintegration of affected side and allows
patient to experience forgotten sensations of normal movement patterns.
Nursing Diagnosis
§ Ineffective Coping
May be related to
§ Situational crises, vulnerability, cognitive perceptual changes
§ 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
Desired Outcomes
§ Verbalize acceptance of self in situation.
§ Talk/communicate with SO about situation and changes that have occurred.

§ Verbalize awareness of own coping abilities.
§ Meet psychological needs as evidenced by appropriate expression of feelings, identification of

options, and use of resources.
§ Assess extent of altered perception and related degree of disability. Determine Functional
Independence Measure score.
§ Rationale: Determination of individual factors aids in developing plan of care/choice of

interventions and discharge expectations.
§ Identify meaning of the dysfunction and change to patient. Note ability to understand events,
provide realistic appraisal of the situation.
§ Rationale: Independence is highly valued in American culture but is not as significant in some
cultures. Some patients accept and manage altered function effectively with little adjustment,
whereas others may have considerable difficulty recognizing and adjust to deficits. In order to
provide meaningful support and appropriate problem-solving, healthcare providers need to
understand the meaning of the stroke/limitations to patient.
§ Determine outside stressors: family, work, future healthcare needs.
§ Rationale: Helps identify specific needs, provides opportunity to offer information and begin
problem-solving. Consideration of social factors, in addition to functional status, is important in
determining appropriate discharge destination.
§ Provide psychological support and set realistic short-term goals. Involve the patient’s SO in plan of
care when possible and explain his deficits and strengths.
§ Rationale: To increase the patient’s sense of confidence and can help in compliance to therapeutic
regimen.
§ Encourage patient to express feelings, including hostility or anger, denial, depression, sense of
disconnectedness.
§ Rationale: Demonstrates acceptance of 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.”
§ Rationale: Suggests rejection of body part and 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 (weak,
affected, right-left) that incorporate that side as part of the whole body.
§ Rationale: 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 of support systems.
§ Rationale: Provides opportunity to use behaviors previously effective, build on past successes, and
mobilize resources.
§ Emphasize small gains either in recovery of function or independence.
§ Rationale: Consolidates gains, helps reduce feelings of anger and helplessness, and conveys sense
of progress.
§ Support behaviors and efforts such as increased interest/participation in rehabilitation activities.
§ Rationale: Suggest possible adaptation to changes and understanding about own role in future
lifestyle.
§ Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope,
lethargy, withdrawal.
§ Rationale: May indicate onset of depression (common after effect of stroke), which may require
further evaluation and intervention.
§ Refer for neuropsychological evaluation and/or counseling if indicated.
§ Rationale: 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.
Nursing Diagnosis
§ Self-Care Deficit
May be related to
§ Neuromuscular impairment, decreased strength and endurance, loss of muscle

control/coordination
§ Pain/discomfort
§ Depression
§ 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
Desired Outcomes
§ Demonstrate techniques/lifestyle changes to meet self-care needs.
§ Perform self-care activities within level of own ability.
§ Identify personal/community resources that can provide assistance as needed.

§ Assess abilities and level of deficit (0–4 scale) for performing ADLs.
§ Rationale: Aids in planning for meeting individual needs.
§ Avoid doing things for patient that patient can do for self, but provide assistance as necessary.
§ Rationale: To maintain self-esteem and promote recovery, it is important for the patient to do as
much as possible for self. These patients may become fearful and independent, although assistance
is helpful in preventing frustration.
§ Be aware of impulsive actions suggestive of impaired judgment.
§ Rationale: May indicate need for additional interventions and supervision to promote patient
safety.
§ Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks. Don’t rush
the patient.
§ Rationale: Patients need empathy and to know caregivers will be consistent in their assistance.
§ Provide positive feedback for efforts and accomplishments.
§ Rationale: Enhances sense of self-worth, promotes independence, and encourages patient to

continue endeavors.
§ Create plan for visual deficits that are present: 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.
§ Rationale: 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: extensions with hooks for picking things up from the floor, toilet risers,
long-handled brushes, drinking straw, leg bag for catheter, shower chair. Encourage good grooming
and makeup habits.
§ Rationale: To enable the patient to manage for self, enhancing independence and self-esteem,
reduce reliance on others for meeting own needs, and enables the patient to be more socially active.
§ Encourage SO to allow patient to do as much as possible for self.
§ Rationale: Reestablishes sense of independence and fosters self-worth and enhances

rehabilitation process. Note: This may be very difficult and frustrating for the 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 periodic intervals for voiding if appropriate.
§ Rationale: 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.
§ Rationale: Assists in development of retraining program (independence) and aids in preventing

constipation and impaction (long-term effects).
§ Teach the patient to comb hair, dress, and wash.
§ Rationale: To promote sense o f independence and self-esteem.
§ Refer patient to physical and occupational therapist.
§ Rationale: Rehabilitation helps to relearn skills that are lost when part of the brain is damaged. It
also teaches new ways of performing tasks to circumvent or compensate for any residual disabilities.
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2022
NTRODUCTION  The entire field of health care is changing day by day.  These changes occurs at
rapid rate.  The focus of medical –surgical nursing is not limited to a disease or a body system but
focus on holistic in nature.  Medical –surgical nursing is a speciality of nursing that requires a
specific skills such as analytical, technical,administrative and organizational skills.  According to
academy of medical –surgical nurses, it is evolving as a speciality and is the largest group of
practicing professional. EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
3. DEFINITIONS Trend: A general direction in which a situation is changing or developing. - Oxford

Advanced Learners Dictionary Issues: An important topic that people are discussing. A problem or
worry that somebody has with some thing EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
4. TRENDS IN MEDICAL SURGICAL NURSING Quantification of nursing care costs Reduced length of
stay Increasing Reliance On High Technology Requirement of advanced nursing knowledge Need
for collaboration and communication Innovation in care planning through computerization
Unification of practice and education EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
5. TRENDS IN MEDICAL SURGICAL NURSING  Greater investment in research and development 

Role blurring and shared competencies  New areas of nursing specialization  Nursing seen as a
cost effective approach to health  Telenursing  Robotic nursing  Aerospace nursing  Community
based nursing EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
6. Quantification of nursing costs • Quantification of nursing contribution to patient care can be used
to determine the cost of providing care to specific patients • Quantifying nursing time requires the
identification of the level of nursing care necessary for each patient. • The patient care plan is an
integral part of the justification of nursing care costs EDWIN JOSE L MEDICAL SURGICAL NURSING
15.02.2021
7. Reduced length of stay The provision of personalized care must be planned and provided with
continuity as the quality of care time decreases. Many patients who leave the hospital earlier are
still need of health care. Aggressive discharge planning must begin on admission. An effective
coordinated plan of care can help ensure continuity of care. EDWIN JOSE L MEDICAL SURGICAL
NURSING 15.02.2021
8. Increase reliance on high technology The evolving technological advances in nursing are the wave
of the future in healthcare. Emerging new technologies in EHRs, AI, apps and software development
are becoming increasingly popular as more hospitals and facilities integrate them into their health
system. EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
9. Requirement of advanced nursing knowledge • The medical –surgical nurse needs greater clinical
expertise, maturity, clinical thinking ability, assertiveness and patient management skills to handle
patients. • Certification acknowledges the nurses attaintment of predetermined standards
established by the certifying groups. EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
10. NEED FOR COLLABORATION AND COMMUNICATION • The health care delivery becomes more
complex and economically centered that need communication and collaboration among health care
professionals. • Only through collaboration between departments, services, and facilities the nursing
care can be delivered effectively. EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
11. Innovation in planning care through computerisation  Nurses believe that their better time can
be spend at the bedside giving patient care rather than filling out paperwork  Studies shows that
institutions using computers reports increases number of plan of care being generated EDWIN JOSE
L MEDICAL SURGICAL NURSING 15.02.2021
12. Unification of practice and education The Unification Model directs nursing education, research,
and practice. Unification is not only a philosophical approach but also an organizational structure
that operationalizes the interdependence among education, research and practice. EDWIN JOSE L
MEDICAL SURGICAL NURSING 15.02.2021
13. Greater investments and developments In the recent years the budget allocation for nursing
research has been increased in the view of increasing the quality of nursing care EDWIN JOSE L
14. Role blurring and shared competencies • Nowadays the role of nurses is not clearly defined •
The work of nurses are shared with other departments EDWIN JOSE L MEDICAL SURGICAL NURSING
15.02.2021
15. Nursing –cost effective approach  The nursing procedures we are doing are evidenced based
and cost effective whwn compare to medical treatment and procedures. EDWIN JOSE L MEDICAL
SURGICAL NURSING 15.02.2021
16. telenursing Tele nursing or telehealth nursing uses technologies to provide nursing services
through computers and mobile devices It allows patients to connect with their nurses through
mobiles devices,computers,applications etc….. EDWIN JOSE L MEDICAL SURGICAL NURSING
15.02.2021
17. Robotic nursing Robots are used in nursing for monitoring elderly patient via video ,helps in
positioning,feeding,shifting etc….. EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
18. Community based nursing The health care delivery concept is now changing from hospital
centered to community based nursing EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
19. Issues in medical surgical nursing  Staff shortage  Meeting patients expectations  Long work
hours  Workplace violence  Workplace hazards  Scope of practice  Personal health EDWIN JOSE
L MEDICAL SURGICAL NURSING 15.02.2021
20. Staff shortages The world health organization estimates that there will be shortage of 1.1
million nurses throught out the world. This may cause disturbances in health care system EDWIN
JOSE L MEDICAL SURGICAL NURSING 15.02.2021
21. Meeting the patients expectations Due to advanced technology and awareness, the patients
expectation are not met. This causes job dissatisfaction among nurses. EDWIN JOSE L MEDICAL
SURGICAL NURSING 15.02.2021
22. Long work hours Shortage of nurses forces the nurses to work for long hours which causes
physical and mental disturbances EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
23. Workplace hazards Needle stick injuries,sharp tools, and heavy equipments may risk the nurses
health and life. EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
24. Scope of practice  The scope of practice for nurses makes nurses to work in a defined area of
practice.  Till now there is no prescribed scope of practice for nurses in India. EDWIN JOSE L
25. Personal health Working in a stressfull health care system causes physical and mental
disequilibrium. EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
26. THANKYOU EDWIN JOSE L MEDICAL SURGICAL NURSING 15.02.2021
rend #1: Nurse shortage will continue
cording to the World Health Organization (WHO), there are 28 million nurses worldwide. Yet that
number still isn't high enough for patient numbers and needs. As a result, there is a global shortage
of nurses, and 6 million more jobs are needed to be filled by 2030 to meet healthcare requirements
for all the patients and their needs.
This number will online continue to rise throughout 2022 as well. Many of the baby boomer
generations are near retirement age, COVID-19 stunted new potential nurses from gaining
education, and as nurse burnout increases, more nurses are leaving the healthcare field as a whole.
The ramifications of COVID-19 and the global nursing shortage are felt throughout healthcare and
will continue to be felt for the next few years.
Trend #2: Nursing jobs numbers will continue to increase
As the nurse shortage continues to be felt throughout healthcare, the number of nursing jobs
available will also continue to rise. With one-third of the current nursing population nearing
retirement age, a large number of new nursing jobs will soon open up. These jobs will be in varying
levels of experience, allowing a variety to come in.
In addition to the influx of jobs from nurses retiring, there are additional jobs opening up around the
country as healthcare systems expand their facilities to accommodate a growing population.
Trend #3: Increased use of online nursing programs
Because of the high demand for nursing professionals, there is high job security in the profession
and a high need for further education. As a result, more colleges and universities provide online
education programs, specifically in nursing. Online education offers a way for nurses to obtain a
degree while working full-time and provides a way for nurses to access higher education set at their
schedule and a way to learn even while under pandemic protocols and restrictions.
Trend #4: Nurses will need higher education, focused on BSN degrees
The growth of online nursing programs has not only made higher education more accessible than
ever, but also
focused on BSN degrees
The growth of online nursing programs has not only made higher education more accessible than
ever, but also increased to expectations hospitals have for their nurses. Healthcare facilities prefer
nurses with at least a BSN, encouraging nurses to seek out higher levels of education.
The number of nursing jobs that will be opening up in the coming years has also led to nurses
needing high education. The nurses who are now coming into the workforce are expected to have
the same level of knowledge and experience as those who have been in the field. This means they
need more education to jumpstart their careers. Higher education, such as Doctor of Nursing
Practice (DNP) programs, are also becoming more necessary for those nursing professionals who are
looking to have a place in leadership.
Trend #5: The rise of telemedicine In 2020, there was a shift in how Americans interacted with
healthcare due to COVID-19, and that included a massive 20% of medical visits being conducted
virtually. There are reports that telemedicine revenue is projected to triple by 2023. The widespread
adoption of telemedicine has helped to automate nurse tasks, and offer more accessible patient
care, as well as telehealth and chatbot options.
Telehealth technology offers flexibility and allows patients to access their documents and doctors
from home, giving them more control of their health care and the ability to feel safe in their homes.
Online portals can be filled with test results, prescription refill requests, and appointments.
Additionally, doctors or nurses can be accessed with telemedicine equipment to host virtual
meetings, saving patients and clinicians valuable time.
Similarly, chatbot services have been introduced to give patients more ownership over their care
received. Patients can schedule appointments, set reminders for medication administration, and
search for specialists in
their area.
Trend #6: Traveling Nurses
The last few years showed how much society needs traveling nurses to meet shifting demands. We
saw thousands of nurses pour into COVID-19 hot spots to support the surging patient volumes.
Travel nursing as an industry grew 30% between January and August of 2021. The lure of higher
compensation amounts, travel opportunities, and a chance to work in different work environments
has influenced the major jump in traveling nurses. With more nurses traveling around the country to
help new patients, more nurses
have been increasingly interested in the profession, keeping this trend around for years to come.
Trend #7: Increased Specialization and Career Path Options
Healthcare needs are becoming increasingly complex. As a result, the scope of specializations that
nurses can practice is widening. With specialization in over 96 areas, including pediatrics, cardiac,
and intensive care, nurses can choose a path that suits them. With the growing complexity of
healthcare, a nurse who specializes is in higher demand than those who do not. As the world grows
and more research and technological advancements come out, nurse career path options become
endless.
Trend #8: Self-Care for Nurses
Nurses are trained caregivers, yet they sometimes forget about themselves. Self-care is a planned
activity to provide for our physical, mental, and spiritual well-being. Lack of self-care can lead to
errors, fatigue, and burnout, which comes at a high cost to patients, nurses, and the healthcare
organization. The stress of the pandemic and increase in workloads have made many nurses put self-
care even further on the back burner. During times of increased stress, self-care should increase, not
decrease. As more research and data come out about the physical and mental strain of nursing,
healthcare leaders worldwide are taking the initiative to acknowledge and treat self-care as an
actual responsibility. It's time for nurses and the facilities they work for to make self-care a top
priority. Self-care can look different for every nurse, and should be centered on their specific needs.
A self-care plan should be specific, measurable, achievable, action-oriented, and time-sensitive.
Trend #9: Nursing informatics will grow
Ever since the American Recovery and Reinvestment required hospitals to adopt electronic medical
records (EMR), hospitals have been adopting systems to correctly store them. This also means they
need staff that can correctly read, interpret, and manage this new data. To keep up with this
growing need, a new specialty within nursing has taken off and will continue to see large amounts of
growth throughout 2022. Nursing informatics (NI) combines nursing with EMRs to properly use
them.
The more EMRs are used in the hospitals, the more of a need there will be for nurse informatics. So
much so,
hat the Advance Healthcare Network for Nurses reports that 70,000 nurse informatics jobs will be
needed in the next few years. Keeping this in the top nursing trends for years to come.
rend #10: Increased salaries and benefits
Because of the lasting effects of the global pandemic, the high levels of stress endured during shifts,
and the shortage of nurses, employers want to offer compensation that keeps their nurses satisfied
and is equivalent to the amount of work they offer. If a nurse is not satisfied with what they are
currently offered, they can shift to another hospital. Hospitals are tailoring care around the patient
experience, and without nurses, they cannot offer a high level of patient care.
To stay in the competition, salaries and benefits will continue to grow so employers retain
employees and attract potential candidates.
Trend #11: Bilingual nurses will be in more
demand
Specifically, in the U.S., bilingualism is becoming increasingly valued. More than 350 languages are
spoken across the states. Instead of having a translator and a nurse, hospitals are looking to combine
the two and offer a seamless offering of care. In the coming years, nurses who speak a second
language, mainly Spanish, will be increasingly in demand.
Trend #12: Increased use of virtual simulation

Technology has progressed to the point where healthcare facilities are able to implement technology
to support virtual simulation training. This allows nurses, both new and old, to receive more
immersive training. Virtual simulations are able to show a variety of different situations, expose
them to situations where they need to employ critical-decisions making, and solve issues where
there’s not enough space for all of the nurses to train in one space.
Trend #13: Holistic care will become more popular
As patients become more educated, they become more in charge of their health. After seeing how
significantly COVID-19 has affected people, both physically and mentally, patients have begun to
become interested in treating all aspects of their person rather than only what is presently wrong.
This has resulted in a growing demand for nurses who provide holistic services and can help them
find the root of their physical issues. Educated nurses trained in providing care and managing health
procedures are ideal candidates for delivering holistic services to patients and will continue to be in
need in the coming years.
Trend #14: Nurses are retiring later
The age of retirement among nurses is getting increasingly higher. Starting when the economy
slowed, those with nursing jobs kept their jobs well into their 60s. Now with the nursing shortage,
nurses are continuing to keep their jobs in hopes of helping. As they age, nurses are moving away
from the physically demanding and transitioning to desk work, but are still able to help patients.
With 40% of nurses over the age of 50 and a projected 82 million nurses to be over 65 by 2030, this
trend is here to stay as more passionate nurses join the field.
Trend #15: Working with more technology
Every day new healthcare technologies enter the market. Nurses are required to adapt to these
technologies to improve patient care. New technology is expanding and is continuously introduced
to reduce administration time, and increase accuracy, all keeping clinician satisfaction and the
patient experience in mind. Nurses are expected to use computer technology, like laptop carts, to
document and obtain patient information and even look up treatment options when necessary.
Intuitive workstations on wheels are becoming increasingly more popular.
Trend #16: Males entering the nurse workforce will rise
In 2011 in the U.S., 1 in 10 nurses were men. This was a 660% increase in the total number of men
since 1981. With the global shortage of nurses, health care organizations will continue to focus on
recruiting men to the field in 2022 and beyond.
Altus commits to improving the delivery of healthcare
With these top nursing trends, navigating how to best follow them can become a pitfall for many
hospitals. That’s why Altus is here to help. Our medical computer carts are built specifically for
nurses so they are able to bring the cart with them from room to room. Whether it’s a new nurse,
one focused on informatics, or even a traveling nurse, these workstations are easy to use and offer a
higher level of comfort while working. Altus computer workstations make following the above top
nursing trends a breeze for nurses and healthcare facilities alike.
Contact Altus to learn more about our workstations on wheels and how they can help your hospital
with these trends.
THICAL PRINCIPLES IN NURSING CARE • Religious Issues • Communication Issues • Family

Organization Issues • Ethical Issues
4. MAJOR TRENDS IN MEDICAL SURGICAL NURSING • Quantification of nursing care costs • Reduced
length of stay • Increasing reliance on high technology • Requirement for advanced nursing
knowledge. • Innovations in care planning through computerization.
5. SIGNIFICANCE OF CULTURE IN NURSING • DEFINITION OF CULTURE: • Culture represents a unique

way of perceiving, behaving and evaluating the external environment and such provides a blue print
for determining values beliefs and practices (Boyle, 2003)
6. CULTURAL VALUES Cultural values are unique expressions of a particular culture that have been
accepted as appropriate over time. They guide actions and decisions making that facilitate self worth
and self esteem (LEININGER, 1985)
7. INDIAN CULTURE • Religion • Language • Family Structure • Health Beliefs • Death And Dying •
Cultural Beliefs
8. ETHICAL ISSUES IN NURSING PRACTICE • Clinical • Professional • Philosophical • Organisational

and societal
9. CONCLUSION • Rapid changes in the health care environment, with continuous technological
advancements, increasing severity of illness, budget constraints, and expanding nursing knowledge,
have greatly increased the responsibilities, facing today’s nurses. To fulfil these responsibilities,
planning and documentation of care are essential to satisfy patient needs and meet legal obligations.
Documentation of the impact of nursing on patient care also provides information for continuing
care needs, legal concerns, and payments.
10. BIBLIOGRAPHY • NANCY.M.HOLLOWAY “MEDICAL SURGICAL CARE PLANNING” 4TH EDITION,

LIPPINCOTT PUBLICATIONS PAGE NO: 2-5. • USHA RAVINDRAN “TEXT BOOK OF MEDICAL SURGICAL”
JAYPEE PUBLICATIONS PAGE NO: 14-15. • PRISCILLA LEMONE, KAREN BRUKE “MEDICAL SURGICAL
NURSING CRITICAL THINKING IN CLIENT CARE” PAGE NO:8 • LYNDA JUALL CARPENITO {2004}
“NURSING CARE PLANS AND DOCUMENTATION” 4TH EDITION PUBLISHED BY LIPPINCOTT WILLIAMS
AND WILKINS.
11. CONT... • GAYLE ROUX, ET.AL “ISSUES AND TRENDS IN NURSING: ESSENTIAL KNOWLEDGE FOR
TODAY AND TOMMOROW” JONES AND BARTLETT PUBLISHERS PAGE NO:14-16 • BARBARA CHERRY,
SUSAN R JACOB “CONTEMPORARY NURSING, ISSUES, TRENDS AND MANAGEMENT” 6TH EDITION
ELSEVIER PUBLICATIONS PAGE NO:5-8 • PERLE SALVIK COWEN SUE MOORHEAD “CURRENT ISSUES
IN NURSING” 8TH EDITION MOSBY ELSEVIER PUBLICATIONS PSGE NO:23-25 • BRUNNER AND
SUDDARTH “TEXT BOOK OF MEDICAL SURGICAL NURSING” VOLUME 1 12TH EDITION, LIPPINCOTT
WILLIAMS AND WILKINS PUBLICATIONS, PAGE NO: 25-26
12. NET REFERENCES • www.netjournels.elseivers.com • Careertrend.com • En.wikipedia.org •

Slideshare.net/medical surgical nursing • Www.books.google.com • JOURNEL REFERENCE •
www.nejm.org • Www.ncbi.nlm.nih.gov.org • https://scholar.google.co.in •
http://www.nursingworld.org • http://journals.lww.com
Evolution and trends of medical surgical Nursing
Evolution Medical Surgical nursing • In ancient times, when medical lore was associated with good
or evil spirits, the sick were usually cared for in temples and houses of worship. • These women had
no real training by today's standards, but experience taught them valuable skills, especially in the
use of herbs and drugs, and some gained fame as the physicians of their era.
In the 17th cent., St. Vincent de Paul began to encourage women to undertake some form of training
for their work, but there was no real hospital training school for nurses until one was established in
Kaiserwerth, Germany, in 1846. • There, Florence Nightingale received the training that later
enabled her to establish, at St. Thomas's Hospital in London, the first school designed primarily to
train nurses rather than to provide nursing service for the hospital • Similar schools were established
in 1873 in New York City, New Haven (Conn.), and Boston.
Nursing subsequently became one of the most important professions open to women until the social
changes brought by the revival of the feminist movement that began in the 1960s. • During the late
nineteenth and early twentieth centuries in the United States, adult patients in many of the larger
hospitals were typically assigned to separate medical, surgical, and obstetrical wards. • Nursing
education in hospital training schools reflected these divisions to prepare nurses for work on these
units
Early National League of Nursing Education (NLNE) curriculum guides treated medical nursing,
surgical nursing, and disease prevention (incorporating personal hygiene and public sanitation) as
separate topics. • By the 1930s, however, advocates recommended that medical and surgical
nursing be taught in a single, interdisciplinary course, because the division of the two was
considered an artificial distinction. Surgical nursing came to be seen as the care of medical patients
who were being treated surgically. • The NLNE's 1937 guide called for a “Combined Course” of
medical and surgical nursing
Students were expected to learn not only the theory and treatment of abnormal physiological
conditions, but also to provide total care of the patient by understanding the role of health
promotion and the psychological, social, and physical aspects that affected a patient's health. While
the integration of this approach into nursing school curricula • 1960s, nursing schools emphasized
the interdisciplinary study and practice of medical and surgical nursing. • 1960s and 1970s,
standards were developed for many nursing specialties, including medical-surgical nursing.
Standards, Medical-Surgical Nursing Practice, written by a committee of the Division on Medical-

Surgical Nursing of the American Nurses' Association (ANA), was published in 1974. It focused on the
collection of data, development of nursing diagnoses and goals for nursing, and development,
implementation, and evaluation of plans of care. • A Statement on the Scope of Medical-Surgical
Nursing Practice followed in 1980.
In 1991, the Academy of Medical-Surgical Nurses (AMSN) was formed to provide an independent
specialty professional organization for medical-surgical and adult health nurses. • . In 1996, the
AMSN published its own Scope and Standards of Medical-Surgical Nursing Practice, • The second
edition appeared in 2000 [15]. Both the ANA and AMSN documents stated that while only clinical
nurse specialists were expected to participate in research, all medical-surgical nurses must
incorporate research findings in their practice.
Trends in medical surgical nursing • Recent trends affecting nursing as a whole have also affected
medical-surgical nurses, including • the increasing use of nursing case management, • expansion of
advanced practice nursing, • total quality improvement, • development of clinical pathways, •
changes in the professional practice model to include greater numbers of nonprofessional staff, •
health care reform, • and the rise of managed care. • The trend toward increased acuity of patients,
begun in the 1980s, has become a fact of life.
Influences on future nursing practice • Expanding knowledge & technology • Healthy people
initiatives • Evidence based practice • Standardized nursing terminologies • Health care informatics
• Nursing informatics
Registered Nurse Licensure Addiction nurse Ambulatory care nurse Perianathesia nurse
Cardiac/vascular Nurse Critical care nurse Emergency nurse Flight nurse Dialysis nurse Bachelor’s
degree in Nursing First assistant nurse Holistic nurse Home health nurse Home health nurse Nursing
administration School nurse Nursing specialty
Masters/higher degree in nursing • Nurse practioneer • Acute care NP, adult care NP, Family NP,
gerontological NP, Palliative Care NP, Pediatric NP. 2. Clinical specialist • Adult psychiatric & mental
health nursing, community health nursing, medical surgical nursing, palliative and pediatric nursing
3. Others • Advanced nursing administration • Advanced oncology clinical specialist • Clinical nurse
leader
History of nursing • Societal Trends Influencing the Development of Nursing • Social Trends •
Ancient Civilizations • Care of sick was related to physical maintenance & comfort • first by family
members, relatives , servants or prisoners • eventually by religious orders or humanitarian societies
• Mental Health • Linda Richards and Dorthea Dix worked to improve the care of the mentally ill •
Modern Civilization • focus in on technology
Societal Trends Influencing the Development of Nursing • Religious Tradition-Catholic/Protestant •

Courage • care of sick in battlefields, military/naval hospitals and prisons • care of sick and dying
during epidemics • cholera, typhus, smallpox • Sacrifice • Creativity • founding of Alcoholic
Anonymous & Al-Anon • Compassion
Societal Trends Influencing the Development of Nursing • Women’s Movement • Nursing has been a
premiere political force for women’s rights • Nurse’s organized the first major professional
organization for women • edited & published the first professional magazine by a female
Martha Danger was a public health nurse in New York • opened the first birth control clinic in U.S.
because of large number of unwanted pregnancies in the working poor • Lavina Dock was a writer &
political activist • early feminist devoted to women’s suffrage • participated in protest &
demonstrations until passage of the 19th Amendment in 1920 • Cultural Factors • first major
professional group to integrate black & white members
Wars • Nightingale in the Crimean War • mortality rate dropped from 60% to 2% as a result of the
environmental changes she implemented • Clara Barton organized nurses to provide care in the
American civil War and established the American Red Cross that serves in war and peace time •
American Red Cross was responsible for recruiting women for the Army Nurse Corp during WWI •
Their motto was , American Nurses for American Men
Economic Factors • Insurance • Fee for service • Managed care • Cost of health care rising faster
than inflation Educational Factors • 1893 Dock with Isabel Hampton Robb and Mary Nutting founded
the American Society of Superintendents of Training Schools for Nurses of the U.S. and Canada • this
organization was very politically active & became the NLN which promotes quality nursing education
to this day
Political Factors • Nightingale was political • first nurse to exert political pressure on government •
influential in reforming hospitals & implementing public health policies in Britain • Clara Barton
persuaded Congress in 1882 to ratify the Treaty of Geneva so the Red Cross could perform in peace
time • impacted on national & international pollicies
Lillian Wald’s political pressure lead to the creation of the U.S. Children’s Bureau • established by
congress in 1912 to oversee child labor laws • Nursing represents 67% of healthcare providers in the
U.S. • few nurses are in positions where they can influence health care policy making
1990s - Nurses became involved in politics at the local, state & national level • Eddie Bernice
Johnson into U.S. House of Representatives from Texas • Ada Sue Hinshaw directed the NIH Center
for Nursing Research • Nurses in all practice areas are affected by public policy on a daily basis • this
demands that all nurses be proactive in policy development • Nursing’s Agenda for Health Care
Reform • developed in 1991 • nurses can use this agenda to unite and become a political force in
health care delivery
Groups of practitioners who band together to perform social or political functions they could not do
alone • Define & regulate the profession • Development of a knowledge base for practice • Research
• Transmit norms, values, knowledge, and skills • Communicate/advocate contributions of the
profession • Address members social & general welfare needs
The nurse shortage is proportional to promising career opportunities and high compensation.
With the demand-supply gap of Nursing professionals, there will be an upward trend in online
nursing programs. With the increased expectations, healthcare will prefer nurses with higher
education degrees. Thus, it’s time to upskill and reskill.
At the time of change, the latest technologies will enter space as a result, it will expect the
professionals to transform as per the technological need.
With the advancements, there’ll be a need for continuous up-gradation. 90% of nurses stated they
require training to perform their professional duties. Nursing training and development is one of the
anticipated trends for 2022.
With a more educated population, there will be an increased focus on the quality of care in Nursing.
Burnout, exhaustion, and moral injury are a cause of concern among the nursing fraternity.
Therefore, for their well-being, steps would be taken to support self-care for nurses.
The space will observe the entry of the male nurses.
Travelling nurses will be in demand to support the surging patient volumes. Elevated compensation
amounts, travel opportunities, and a chance to work in different work environments will influence
the major jump in travelling nurses.
Nursing Informatics, a new speciality within nursing will gain popularity and observe significant
amounts of growth throughout 2022.
The demand for home healthcare nurses will meet popularity as the population ages.
The nurse shortage is proportional to promising career opportunities and high compensation.
With the demand-supply gap of Nursing professionals, there will be an upward trend in online
nursing programs. With the increased expectations, healthcare will prefer nurses with higher
education degrees. Thus, it’s time to upskill and reskill.
At the time of change, the latest technologies will enter space as a result, it will expect the
professionals to transform as per the technological need.
With the advancements, there’ll be a need for continuous up-gradation. 90% of nurses stated they
require training to perform their professional duties. Nursing training and development is one of the
anticipated trends for 2022.
With a more educated population, there will be an increased focus on the quality of care in Nursing.
Burnout, exhaustion, and moral injury are a cause of concern among the nursing fraternity.
Therefore, for their well-being, steps would be taken to support self-care for nurses.
The space will observe the entry of the male nurses.
Travelling nurses will be in demand to support the surging patient volumes. Elevated compensation
amounts, travel opportunities, and a chance to work in different work environments will influence
the major jump in travelling nurses.
Nursing Informatics, a new speciality within nursing will gain popularity and observe significant
amounts of growth throughout 2022.
The demand for home healthcare nurses will meet popularity as the population ages.
Lachman, Vicki D. "Ethical concerns in medical-surgical nursing." MedSurg Nursing, vol. 25, no. 6,
Nov.-Dec. 2016, pp. 429+. Gale Academic OneFile, link.gale.com/apps/doc/A476729517/AONE?
u=anon~c6904524&sid=googleScholar&xid=d17e0f6b. Accessed 28 Oct. 2022.
Disclaimer
INTRODUCTION Nursing has been called the oldest of the art, and the youngest of the profession. As
such, it has gone through many stages and has been an integral part of social movements. Nursing
has been involved in in the existing culture, shaped by it and yet beeping to develop it. The trend
analysis and future scenarios provide a basis for sound decision making through mapping of possible
futures and aiming to create preferred futures. 5
6. The world health organization (who) has been considering the future and predicts that by 2000
the world experiences: Major growth in the elderly population Decline in birth rate, especially in
western counteries Increase in chronic illness Continuing social unrest AIDS a major problem Many
infectious diseases under control Mental health a key issue Poverty continuing to plague mach of the
world 6
7. TRENDS IN NURSING: 1. Education changes due to changes in demographics 2. Embracing of

technology 3. Advancements in communication and technology 4. Working with more educated
consumers 5. Increasing complexity of patient care 7
8. TRENDS IN NURSING(continue): 6. Increased cost of health care 7. Changes in federal and state
regulation 8. Interdisciplinary skills 9. Nurses working beyond retirement age 10. Advances in nursing
and science research. 8
9. TRANSITIONS TAKING PLACE IN HEALTH CARE: Curative - Preventive approach Specialized care -
Primary health care Medical diagnosis - Patient emphasis Discipline stovepipes - Programme
stovepipes Professional identity - Team identity Trial and error - Evidence based practice Self
regulation - Questioning of professions Focus on quality - Focus on costs 9
10. IN THE WORKPLACE: High tech - Humanistic Competition - Cooperation Need to supervise -
Caching, mentoring Hierarchies - Decentralized approach 10
11. IN NURSING Continued competencies - Competencies a condition Hospital environment -

Community environment Quality as excellence - Quality as safe Clear role - Blurring roles 11
Structures and Functions of Nervous System
Left hemisphere of cerebrum, lateral surface, showing major lobes and areas of the brain.
3 Structures and Functions of Nervous System
Structural features of neurons: dendrites, cell body, and axons.
Major divisions of the central nervous system (CNS).
The cranial nerves are numbered according to the order in which they leave the brain.
Arteries of the head and neck. Brachiocephalic artery, right common carotid artery, right subclavian
artery, and their branches. The major arteries to the head are the common carotid and vertebral
arteries.
Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior
cerebral arteries joined to each other by the anterior communicating cerebral artery and to the
posterior
cerebral arteries by the posterior communicating arteries.
The vertebral column (three views).
9 Stroke
Stroke occurs when ischemia or hemorrhage into the brain results in death of brain cells.
Also known as a brain attack
Functions are lost or impaired
Such as movement, sensation, or emotions that were controlled by the affected area of the brain
Severity of the loss of function varies according to the location and extent of the brain involved.
The term brain attack communicates the urgency of recognizing the clinical manifestations of a
stroke and treating a medical emergency, similar to what would be done with a heart attack.
10 Risk Factors
Most effective way to decrease the burden of stroke is prevention.
Risk factors can be divided into non modifiable and modifiable risks.
11 Risk Factors Modifiable Non modifiable Hypertension Metabolic syndrome
Heart disease
Heavy alcohol consumption
Poor diet
Drug abuse
Sleep apnea
Obesity
Physical inactivity
Smoking
Non modifiable
Age
Gender
Race
Heredity/family history
Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes
occur in individuals >65 years.
Strokes are more common in men, but more women die from stroke than men.
African Americans have a higher incidence of stroke as well as a higher death rate from stroke than
whites.
12 Types of Stroke
Strokes are classified on the basis of underlying pathophysiologic findings.
Ischemic
Thrombotic
Embolic
Hemorrhagic
13 Major Types of Stroke
14 Ischemic Stroke Ischemic strokes result from
Inadequate blood flow to the brain from partial or complete occlusion of an artery
80% of all strokes are ischemic strokes.
Ischemic strokes can be
Thrombotic
Embolic
15 Ischemic Stroke
Thrombotic stroke
Thrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot.
Result of thrombosis or narrowing of the blood vessel
Most common cause of stroke
Lacunar strokes
a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the
infarcted brain tissue.
thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate
atherosclerosis
Two thirds of thrombotic strokes are associated with hypertension or diabetes mellitus, both of
which accelerate atherosclerosis.
In 30% to 50% of individuals, thrombotic strokes have been preceded by a TIA.
Most patients with ischemic stroke do not have a decreased level of consciousness in the first 24
hours, unless it is due to a brainstem stroke or other conditions such as seizures, increased ICP, or
hemorrhage.
A lacunar stroke refers to a stroke from occlusion of a small penetrating artery with development of
a cavity in the place of the infarcted brain tissue. This most commonly occurs in the basal ganglia,
thalamus, internal capsule, or pons.
16 Pathogenesis of Atherosclerosis
A, Damaged endothelium.
B, Diagram of fatty streak and lipid core formation.
C, Diagram of fibrous plaque. Raised plaques are visible: Some are yellow, others are white.
D, Diagram of complicated lesion: Thrombus is red, collagen is blue. Plaque is complicated by red
thrombus deposition.
A, Damaged endothelium.
B, Diagram of fatty streak and lipid core formation.
C, Diagram of fibrous plaque. Raised plaques are visible: some are yellow, others are white.
D, Diagram of complicated lesion: thrombus is red, collagen is blue. Plaque is complicated by
red thrombus deposition.
17 Pathogenesis of Atherosclerosis
Developmental stages:
Fatty streaks
Earliest lesions
Characterized by lipid-filled smooth muscle cells
Potentially reversible
Fibrous plaque
Beginning of progressive changes in the arterial wall
Lipoproteins transport cholesterol and other lipids into the arterial intima.
Fatty streak is covered by collagen, forming a fibrous plaque that appears grayish or whitish.
Result = Narrowing of vessel lumen

Complicated lesion
Continued inflammation can result in plaque instability, ulceration, and rupture.
Platelets accumulate and thrombus forms.
Increased narrowing or total occlusion of lumen
These changes can appear in the coronary arteries by age 30 and can increase with age.
18 Ischemic Stroke Embolic stroke
Occurs when an embolus lodges in and occludes a cerebral artery
Results in infarction and edema of the area supplied by the involved vessel
Second most common cause of stroke
Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms.
Onset of embolic stroke is usually sudden and may or may not be related to activity.
Patient usually remains conscious, although he may have a headache.
19 Ischemic Stroke Transient ischemic attack
Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia,
without acute infarction of the brain
Symptoms last <1 hour
Most TIAs resolve
encourage patients to go to the emergency room at symptom onset since once a TIA starts, one does
not know if it will persist and become a true stroke, or if it will resolve.
In general, one third of individuals who experience a TIA will not experience another event, one third
will have additional TIAs, and one third will progress to stroke.
20 Hemorrhagic Stroke Intracerebral hemorrhage
Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles
Often a sudden onset of symptoms, with progression over minutes to hours because of ongoing
bleeding
Intracerebral hemorrhage
Bleeding within the brain caused by rupture of a vessel
Hypertension is the most important cause.
Hemorrhage commonly occurs during periods of activity.

21 Hemorrhagic Stroke
Massive hypertensive hemorrhage rupturing into a lateral ventricle of the brain.
Massive hypertensive hemorrhage rupturing into a lateral ventricle of the brain.
22 Hemorrhagic Stroke Intracerebral hemorrhage Manifestations
Neurologic deficits
Headache
Nausea and/or vomiting
Decreased levels of consciousness
Hypertension
Approximately half of intracerebral hemorrhages occur in the putamen and internal capsule, central
white matter, thalamus, cerebellar hemispheres, and pons.
Initially, patients experience a severe headache with nausea and vomiting.
23 Hemorrhagic Stroke Subarachnoid hemorrhage
Intracranial bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater
Commonly caused by rupture of a cerebral aneurysm
Majority of aneurysms are in the circle of Willis.
“Worst headache of one’s life”
Other causes of subarachnoid hemorrhage include trauma and illicit drug (cocaine) abuse.
people who have a hemorrhagic stroke due to a ruptured aneurysm can die during the first episode
or die from subsequent bleeding.
increases with age,
higher in women than men.
Loss of consciousness may or may not occur.
focal neurologic deficits (including cranial nerve deficits), nausea, vomiting, seizures, and stiff neck.
Most frequent surgical procedure to prevent re bleeding is clipping of the aneurysm.
24 Clinical Manifestations
Affects many body functions
Motor activity
Elimination
Intellectual function
Spatial-perceptual
Personality
Affect
Sensation
Communications
The neurologic manifestations do not significantly differ between ischemic and hemorrhagic stroke.
The reason for this is that destruction of neural tissue is the basis for neurologic dysfunction caused
by both types of stroke.
{See future slide for the difference between left- and right-sided stroke.}
25 Clinical Manifestations Motor Function
Most obvious effect of stroke
Include impairment of
Mobility
Respiratory function
Swallowing and speech
Gag reflex
Self-care abilities
Loss of skilled voluntary movement
Alterations in muscle tone
Alterations in reflexes
Symptoms are caused by the destruction of motor neurons in the pyramidal pathway (nerve fibers
from the brain that pass through the spinal cord to the motor cells).
26 Clinical Manifestations Motor Function
An initial period of flaccidity
(also known as hypotonicity is a condition characterized by a decrease or loss of normal muscle tone
due to the deterioration of the lower motor nerve cells).
May last from days to several weeks
Related to nerve damage

Spasticity of the muscles follows the flaccid stage.
(an abnormal increase in muscle tension and a reduced ability of a muscle to stretch)
Related to interruptions in upper motor neuron influence
Because the pyramidal pathway crosses at the level of the medulla, a lesion on one side of the brain
affects motor function on the opposite side of the body (contralateral).
27 Clinical Manifestations Communication
Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain.
Aphasia is the total loss of comprehension and use of language.
Dysphasia refers to difficulty related to the comprehension or use of language and is due to partial
disruption or loss.
The left hemisphere is dominant for language skills in right-handed persons and in most left-handed
persons.
Aphasia occurs when a stroke damages the dominant hemisphere of the brain.
28 Types of Aphasia Broca’s Wernicke’s Global
Damage to frontal lobe, speak in short phrases that makes sense but with great effort. “Walk
doge””Book –book table”. They are aware of it and become frustrated.
Wernicke’s
Left temporal lobe damage. Long sentences with no meaning, difficult to understand the meaning of
the speech. They are not aware of it.
Global
Severe communication difficulties, limited in ability to speak.
A massive stroke may result in global aphasia, in which all communication and receptive function are
lost.
29 Clinical Manifestations Communication
Many patients experience dysarthria.
Disturbance in the muscular control of speech
Dysarthria does not affect the meaning of communication or the comprehension of language, but it
does affect the mechanics of speech.
Some patients experience a combination of aphasia and dysarthria.
Impairments may involve

Pronunciation
Articulation
Phonation
30 Clinical Manifestations Affect
Patients who suffer a stroke may have difficulty controlling their emotions.
Depression and feelings associated with changes in body image and loss of function can make this
worse.
Patients may also be frustrated by mobility and communication problems.
Emotional responses may be exaggerated or unpredictable.
An example of unpredictable affect is as follows:
A well-respected lawyer has returned home from the hospital following a stroke. During meals with
his family, he becomes frustrated and begins to cry because of difficulty getting food into his mouth
and chewing, something that he was able to do easily before his stroke.
31 Clinical Manifestations Intellectual Function
Both memory and judgment may be impaired as a result of stroke.
A left-brain stroke is more likely to result in memory problems related to language.
32 Clinical Manifestations Spatial–Perceptual Alterations
Stroke on the right side of the brain is more likely to cause problems in spatial-perceptual
orientation.
However, this may occur with left-brain stroke.
An example of behavior with right-brain stroke is the patient who tries to rise quickly from a
wheelchair without locking the wheels or raising the footrests.
The patient with a left-brain stroke would move slowly and cautiously from the wheelchair.
33 Clinical Manifestations Spatial-Perceptual Alterations
Spatial-perceptual problems may be
Incorrect perception of self and illness
perception of self in space
Inability to recognize an object by sight, touch, or hearing
Inability to carry out learned sequential movements on command

A stroke on the right side of the brain is more likely to cause problems in spatial-perceptual
orientation, although this can also occur with left-brain stroke as well.
34 Clinical Manifestations Elimination
Most problems with urinary and bowel elimination occur initially and are temporary.
When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is
intact
partial sensation of bladder and voluntary urination is present
Initially, the patient may experience frequency, urgency, and incontinence.
Constipation is associated with immobility, weak abdominal muscles, dehydration, and diminished
response to the defecation reflex.
35 Diagnostic Studies
When symptoms of a stroke occur, diagnostic studies are done to
Confirm that it is a stroke
Identify the likely cause of the stroke
CT is the primary diagnostic test used after a stroke.
A CT scan can rapidly distinguish between ischemic and hemorrhagic stroke and help determine the
size and location of the stroke. Serial CT scans may be used to assess the effectiveness of treatment
and to evaluate recovery.
36 Diagnostic Studies CTA MRI, MRA Cerebral angiography
CT angiography (CTA) provides visualization of cerebral blood vessels
MRI, MRA
MRI is used to determine the extent of brain injury
Angiography may detect vascular lesions and blocksges
Cerebral angiography
Angiography can identify cervical and cerebrovascular occlusion, atherosclerotic plaques, and
malformation of vessels
Digital subtraction angiography
Intraarterial digital subtraction angiography (DSA) reduces the dose of contrast material, uses
smaller catheters, and shortens the length of the procedure compared with conventional
angiography
Transcranial Doppler ultrasonography

Transcranial Doppler (TCD) ultrasonography is a noninvasive study that measures the velocity of
blood flow in the major cerebral arteries.
Lumbar puncture
LICOX system
The LICOX system may be used as a diagnostic tool for evaluating the progression of stroke, brain O2
and temperature, page 1432
37 LICOX catheter
The LICOX brain tissue oxygen system involves a catheter inserted through an intracranial bolt ,
placed in white matter of the brain. (A). The system measures oxygen in the brain (PbtO2), brain
tissue temperature, and intracranial pressure (ICP) (B).
38 Diagnostic Studies of Nervous System
Normal images of the brain. A, CT scan. B, MRI.
38
39 Diagnostic Studies of Nervous System
Cerebral angiogram illustrating an arteriovenous malformation (arrow).
40 Collaborative Care Prevention
Goals of stroke prevention include
Health promotion
Education and management of modifiable risk factors
Patients with known risk factors require close management.
Diabetes mellitus
Hypertension
Obesity
High serum lipids
Cardiac dysfunction
Antiplatelet drugs are usually the chosen treatment
Aspirin is the most frequently used as antiplatelet agent.

Common dose for aspirin is 81 to 325 mg/day.
Other drugs include ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), and combined
dipyridamole and aspirin (Aggrenox).
Oral anticoagulation using warfarin is the treatment of choice for individuals with atrial fibrillation.
Surgical interventions
Carotid end-arterectomy (tube inserted above and below the blockage, remove the plaque, stitch
the artery close, remove the tube)
Transluminal angioplasty (insertion of balloon to open artery in the brain and to improve blood flow)
Stenting (inflate the balloon cath, imlpant the stent, deflate the balloon and remove, leave the stent
permanently in place holding the artery open to improve the blood flow)
Extracranial-intracranial bypass (EC-IC) anastomosing (surgically connecting) external artery to

internal artery- superficial temporal to middle cerebral artery
Evaluation must be done to confirm that the signs and symptoms of a TIA are not related to other
brain lesions, such as a developing subdural hematoma or an increasing tumor mass.
{See next 2 slides for figures of carotid endarterectomy and stenting.}
EC-IC bypass involves anastomosing (surgically connecting) a branch of an extracranial artery to an

intracranial artery (most commonly, superficial temporal to middle cerebral artery) beyond an area
of obstruction, with the goal of increasing cerebral perfusion. This procedure is generally reserved
for those patients who do not benefit from other forms of therapy.
43 Carotid End-arterectomy
Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted
above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common
carotid
artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may
also
perform the technique without rerouting the blood flow.
44 Brain Stent
Brain stent is used to treat blockages in cerebral blood flow.
A, A balloon catheter is used to implant the stent into an artery of the brain.
B, The balloon catheter is moved to the blocked area of the artery and then is inflated. The stent
expands because of inflation of the balloon.
C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery
open and improving the flow of blood.
Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant
the
stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery
and then
inflated. The stent expands due to the inflation of the balloon. C, The balloon is deflated and
withdrawn,
leaving the stent permanently in place holding the artery open and improving the flow of blood.
45 Collaborative Care Acute Care
Goals for collaborative care during the acute phase are
Preserving life
Preventing further brain damage
Reducing disability
Begins with managing the ABCs
Airway
Breathing
Circulation
About 25% of patients will worsen in the first 24 to 48 hours.
Causes
Sudden vascular compromise causing disruption of blood flow to the brain
Thrombosis
Trauma
Aneurysm
Embolism
Hemorrhage
47 Collaborative Care:Acute Care
Assessment findings
Altered level of consciousness
Weakness, numbness, or paralysis
Speech or visual disturbances
Severe headache
↑ or ↓ heart rate
Respiratory distress
Unequal pupils
Hypertension
Facial drooping on affected side
Difficulty swallowing
Seizures
Bladder or bowel incontinence
Nausea and vomiting
Vertigo
( not bell’s pulsy)
Interventions
Ensure patent airway.
Call stroke code or stroke team.
Remove dentures.
Perform pulse oximetry.
Maintain adequate oxygenation.
Obtain IV access.
Maintain BP.
Obtain CT scan immediately.
Perform baseline laboratory tests.
Position head midline.
Elevate head of bed 30 degrees if no symptoms of shock or injury occur.
Institute seizure precautions.
Anticipate thrombolytic therapy for ischemic stroke.

Watch for hypertension post stroke.
Drugs to lower BP are used only if BP is markedly increased. (metoprolol, cardene)
Fluid and electrolyte balance must be controlled carefully.
Adequate hydration promotes perfusion and decreases further brain injury.
Adequate fluid intake during acute care via oral, intravenous (IV), or tube feedings should be 1500 to
mL/day.
Overhydration may compromise perfusion by increasing cerebral edema.
Interventions
Monitor vital signs and neurologic status.
Level of consciousness
Monitor sensory function
Pupil size and reactivity
O2 saturation
Cardiac rhythm
51 Collaborative Care: Acute Care
Recombinant tissue plasminogen activator (tPA)
Used to reestablish blood flow through a blocked artery to prevent cell death in patients with acute
onset of ischemic stroke symptoms
Must be administered within 3 to 4.5 hours of onset of clinical signs of ischemic stroke
Pt screened before tPA can be given:
non contrast CT or MRI scan to rule out hemorrhagic stroke
blood tests for coagulation disorders
screening for recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3
months, or
major surgery within 14 days.

Aspirin is used within 24 to 48 hours of stroke.
Platelet inhibitors and anticoagulants may be used in thrombus and embolus stroke patients after
stabilization.
Contraindicated for patients with hemorrhagic stroke
The use of anticoagulants (e.g., heparin) in the emergency phase following an ischemic stroke
generally is not recommended because of the risk for intracranial hemorrhage.
Dose of aspirin is 325 mg.
Common anticoagulants include warfarin (Coumadin).
Platelet inhibitors include aspirin, ticlopidine (Ticlid), clopidogrel (Plavix), and dipyridamole
(Persantine).
Surgical interventions for stroke
Ischemic stroke
MERCI (mechanical embolus removal in cerebral ischemia)
Hemorrhagic stroke
Immediate evacuation of aneurysm-induced hematomas
Cerebellar hematomas >3 cm
After stroke has stabilized for 12 to 24 hours, collaborative care shifts from preserving life to
lessening disability and attaining optimal functioning.
Patient may be transferred to a rehabilitation unit, outpatient therapy, or home care–based

rehabilitation.
54 Merci Embolus Retriever in Cerebral Ischemic Stroke
The MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. The
retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is
pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny
loops that latch onto the clot, and the clot can then be pulled out. To prevent the clot from breaking
off, a balloon at the end of the catheter inflates to stop blood flow through the artery.
The MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. The
retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is
pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny
loops that latch onto the clot and the clot can then be pulled out. To prevent the clot from breaking
off, a balloon at the end of the catheter inflates to stop blood flow through the artery.
55 Clipping and Wrapping of Aneurysms
56 GDC Coil: Gugleilmi detachable coils
A, A coil is used to occlude an aneurysm. Coils are made of soft, spring like platinum. The softness of
the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little
threat of rupture of the aneurysm.
B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is
threaded up to the cerebral blood vessels.
C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the
aneurysm until the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood
from circulating through the aneurysm, reducing the risk of rupture.
57 Nursing Management Nursing Assessment
If the patient is stable, obtain
Description of the current illness with attention to initial symptoms
History of similar symptoms previously experienced
Current medications
History of risk factors and other illnesses
Family history of stroke or cardiovascular disease
Subjective and objective data that should be obtained from a person who has had a stroke are
presented in Table 58-7.
58 Nursing Management Nursing Assessment
Comprehensive neuro examination
Level of consciousness
Cognition
Motor abilities
Cranial nerve function
Sensation
Deep tendon reflexes
59 Nursing Management Nursing Diagnoses
Risk for ineffective cerebral tissue perfusion
Ineffective airway clearance

Impaired physical mobility
Impaired verbal communication
Impaired urinary elimination
Impaired swallowing
Situational low self-esteem
60 Nursing Management Planning
Goals are that the patient will
Maintain stable or improved level of consciousness
Attain maximum physical functioning
Maximize self-care abilities and skills
Maintain stable body functions
Maximize communication abilities.
Avoid complications of stroke.
Maintain effective personal and family coping.
61 Nursing Management Nursing Implementation
Health promotion
To reduce the incidence of stroke, the nurse should focus teaching toward stroke prevention.
Particularly in persons with known risk factors
Education about hypertension control and adherence to medication
Teaching patients and families about
Early symptoms
Stroke
TIA
When to seek health care for symptoms
Nursing measures to reduce risk factors for stroke are similar to those for coronary artery disease.
Uncontrolled hypertension is the primary cause of stroke. The nurse will need to be an advocate for
the monitoring and management of hypertension, including assessing financial need and
prescription coverage.

Respiratory system
Management of the respiratory system is a nursing priority.
Risk for atelectasis
Risk for aspiration pneumonia
Risks for airway obstruction
May require tracheal intubation and mechanical ventilation
Advancing age and immobility increase the risk for atelectasis and pneumonia.
Risk for aspiration pneumonia is high because of impaired consciousness or dysphagia.
All patients should be effectively screened for their ability to swallow and kept NPO until dysphagia
has been ruled out.
Nursing interventions to support adequate respiratory function are individualized to meet the needs
of the patient (include frequent assessment of airway patency and function, oxygenation, suctioning,
patient mobility, positioning of the patient to prevent aspiration, and encouraging deep breathing).
Interventions related to maintenance of airway function are described in NCP 58-1.
Neurologic system
Monitor closely to detect changes suggesting
Extension of the stroke
↑ ICP
Vasospasm
Recovery from stroke symptoms
Table 58-8, page 1472 the NIH Stroke Scale (NIHSS)national institutes of health stroke scale .
64 Nursing Management: Nursing Implementation
Cardiovascular system
Goals aimed at maintaining homeostasis
Many patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac
disease.
Monitoring vital signs frequently
Monitoring cardiac rhythms
Calculating intake and output, noting imbalances

Regulating IV infusions
Adjusting fluid intake to the individual needs of the patient
Monitoring lung sounds for crackles and rhonchi (pulmonary congestion)
Monitoring heart sounds for murmurs
After stroke, patient is at risk for deep vein thrombosis.
Related to immobility, loss of venous tone, and ↓ muscle pumping in leg
Most effective prevention is keeping the patient moving.
Musculoskeletal system
Goal is to maintain optimal function.
prevention of joint contractures and muscular atrophy
range-of-motion exercises and positioning are important.
Paralyzed or weak side needs special attention when positioned.
Avoidance of pulling the patient by the arm to avoid shoulder displacement
Hand splints to reduce spasticity
Passive range-of-motion exercise is begun on the first day of hospitalization.
If the stroke is due to subarachnoid hemorrhage, movement is limited to the extremities.
Specific deformities on the weak or paralyzed side that may be present in patients with stroke
include internal rotation of the shoulder; flexion contractures of the hand, wrist, and elbow; external
rotation of the hip; and plantar flexion of the foot.
Integumentary system
Susceptible to breakdown related to
Loss of sensation
Decreased circulation
Immobility
Compounded by patient age, poor nutrition, dehydration, edema, and incontinence
Pressure relief by position changes, special mattresses, or wheelchair cushions
Good skin hygiene
Early mobility
Position patient on the weak or paralyzed side for only 30 minutes.
Gastrointestinal system
Stress of illness.
Constipation.
Patients may be placed on stool softeners.
Physical activity promotes bowel function.
Urinary system
promote normal bladder function.
Avoid the use of indwelling catheters.
If the patient does not have a daily or every-other-day bowel movement, check the patient for
impaction. The patient who has liquid stools should also be checked for stool impaction.
Depending on the patient’s fluid balance status and swallowing ability, fluid intake should be at least
1800 to 2000 mL/day and fiber intake up to 25 g/day.
Nutrition
Nutritional needs require quick assessment and treatment.
May initially receive IV infusions to maintain fluid and electrolyte balance
May require nutritional support
First feeding should be approached carefully.
Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding.
Feedings must be followed by oral hygiene.
Communication
Nurse’s role in meeting psychologic needs of the patient is primarily supportive.
Patient is assessed for both the ability to speak and the ability to understand.
Speak slowly and calmly, using simple words or sentences.
Gestures may be used to support verbal cues.

Sensory-perceptual alterations
Blindness in same half of each visual field is a common problem after stroke.
Known as homonymous hemi anopsia
A neglect syndrome (decrease in safety, increase risk for injury)
Other visual problems may include
Diplopia (double vision)
Ptosis (drooping eyelid)
71 Homonymous Hemianopsia (Food on left side is not seen)
Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemi anopsia
Shows that food on the left side is not seen and thus is ignored.
Coping
Affects family
Emotionally
Socially
Financially
Changing roles and responsibilities
Explain
What has happened
Diagnosis
Therapeutic procedures
Should be clear and understood by patient.
social services referral is often helpful.
During the acute phase of caring for the stroke patient and the family, nursing interventions
designed to facilitate coping involve providing information and emotional support.
73 Nursing Management: Nursing Implementation
Ambulatory and home care

Patient is usually discharged to home, an intermediate or long-term care facility, or a rehabilitation
facility.
discharge planning with the patient and family starts early in the hospitalization and promotes a
smooth transition from one care setting to another.
prepare the patient and family for discharge through
Education
Demonstration
Practice
Evaluation of self-care skills
Rehabilitation to promote optimal functioning.
Physical, mental, and social well-being
74 Loss of Postural Stability
Loss of postural stability is common after stroke. The patient is unable to sit upright and tends to fall
sideways. Appropriate support with pillows or cushions should be provided.
Ambulatory and home care (cont’d)
Musculoskeletal interventions
Balance training
Transferring from bed to chair
Bobath method
Therapists and nurses use the Bobath approach to encourage normal muscle tone, normal
movement, and promotion of bilateral function of the body.
An example is to have the patient transfer into the wheelchair using the weak or paralyzed side and
the stronger side to facilitate more bilateral functioning.
CIMT is a more recent approach. Constraint-induced movement therapy (CIMT) encourages the
patient to use the weakened extremity by restricting movement of the normal extremity. This
approach is challenging, and the ability of patients to comply may limit its use.
Ambulatory and home care (cont’d)
After acute phase, a dietitian can assist in determining appropriate daily caloric intake based on the
patient’s
Size
Weight
Activity level
Nurse and speech therapist must assess ability of patient to swallow solids and fluids and must
adjust the diet appropriately.
Inability to feed oneself can be frustrating and may result in malnutrition and dehydration.
77 Assistive Devices for Eating
A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips
and swivel handles are helpful for some persons.
B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a
fork in one hand and a knife in the other.
C, Plate guards help keep food on the plate.
D, Cup with a special handle.
A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips
are helpful for some persons.
B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a
fork in one hand and a knife in the other.
C, Plate guards help keep food on the plate.
D, Cup with special handle.
Implement a bowel management program for problems with
Bowel control
Constipation
Incontinence
High-fiber diet and adequate fluid intake
Patients with stroke frequently have constipation, which responds to the following dietary
management:
●Fluid intake of 2500 to 3000 mL daily unless contraindicated
●Prune juice (120 mL) or stewed prunes daily
●Cooked fruit 3 times daily
●Cooked vegetables 3 times daily

●Whole-grain cereal or bread 3 to 5 times daily
Patients with stroke on right side of brain
Difficulty in judging position, distance, and movement
Impulsive, impatient, and denying problems related to stroke
Respond best to directions given verbally
Patients with stroke on left side of brain
Slower in organization and performance of tasks
Impaired spatial discrimination
Have fearful, anxious response to stroke
Respond well to nonverbal cues
Interventions for atypical emotional response
Distract the patient.
Explain that emotional outbursts may occur.
Maintain a calm environment.
Avoid shaming.
Patients with a stroke may be coping with many losses
Often go through the process of grief
Some patients experience long-term depression
Support communication between the patient and family.
Discuss lifestyle changes.
Discuss changing roles within the family.
Be an active listener.
Include family in goal planning and patient care.
Support family conferences.
Family members must cope with

Recognition of behavioral changes resulting from neurologic deficits that are not changeable
Responses to multiple losses by both the patient and the family.
Behaviors that may have been reinforced during the early stages of stroke as continued dependency
Stroke support groups within rehab facilities and community are helpful.
Mutual sharing
Education
Coping
Understanding
Speech, comprehension, and language deficits are the most difficult problem for the patient and
family.
Speech therapists can assess and formulate a plan to support communication.
Nurses can be a role model for patients with aphasia.
83 Question #1
A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a
thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the
patient: 1. Is ready for aggressive rehabilitation. 2. Will show gradual improvement of the initial
neurologic deficits. 3. May show signs of deteriorating neurologic function as cerebral edema
increases. 4. Should not be turned or exercised to prevent extension of the thrombus and increased
neurologic deficits.
Rationale: Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral
edema increase.
84 Question #2
While performing health screening at a health fair, the nurse identifies which of the following
individuals at greatest risk for experiencing a stroke? 1. A 46-year-old white female with
hypertension and oral contraceptive use for 10 years. 2. A 58-year-old white male salesman who has
a total cholesterol level of 285 mg/dL. 3. A 42-year-old African American female with diabetes
mellitus who has smoked for 30 years. 4. A 62-year-old African American male with hypertension
who is 35 pounds overweight.
Answer: 4
Rationale: Option 4: This individual has five risk factors: age, African American, male, hypertension,
and overweight. Option 1: This individual has two risk factors: hypertension and oral contraception
use. Option 2: This individual has two risk factors: male and increased cholesterol level. Option 3:
This individual has three risk factors: African American, diabetes mellitus, and smoking.
Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity. Stroke
risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes occur in
individuals >65 years. Strokes are more common in men, but more women die from stroke than
men. Because women tend to live longer than men, they have more opportunity to suffer a stroke.
African Americans have a higher incidence of stroke, as well as a higher death rate from stroke than
whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases
the risk of stroke. Modifiable risk factors are those that can potentially be altered through lifestyle
changes and medical treatment, thus reducing the risk of stroke. Modifiable risk factors include
hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive
alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet,
and drug abuse.
Early forms of birth control pills that contained high levels of progestin and estrogen increased a
woman’s chance of experiencing a stroke, especially if she also smoked heavily. Newer, low-dose
oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and
smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory
conditions, and hyperhomocysteinemia. Sickle cell disease is another known risk factor for stroke.
85 Answer #2 Answer: 4 Rationale:
Option 4: This individual has five risk factors: age, African American, male, hypertension, and
overweight.
Option 1: This individual has two risk factors: hypertension and oral contraception use.
Option 2: This individual has two risk factors: male and increased cholesterol level.
Option 3: This individual has three risk factors: African American, diabetes mellitus, and smoking.
86 Answer #2
Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity. Stroke
risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes occur in
individuals >65 years. Strokes are more common in men, but more women die from stroke than
men. Because women tend to live longer than men, they have more opportunity to suffer a stroke.
African Americans have a higher incidence of stroke, as well as a higher death rate from stroke than
whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases
the risk of stroke.
Modifiable risk factors are those that can potentially be altered through lifestyle changes and
medical treatment, thus reducing the risk of stroke. Modifiable risk factors include hypertension,
increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive alcohol
consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and
drug abuse.
Early forms of birth control pills that contained high levels of progestin and estrogen increased a
woman’s chance of experiencing a stroke, especially if she also smoked heavily. Newer, low- dose
oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and
smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory
conditions. Sickle cell disease is another known risk factor for stroke.
87 Question #3
A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following
actions should the nurse take first? 1. Check the patient’s gag reflex. 2. Request a soft diet with no
liquids. 3. Place the patient in high-Fowler’s position. 4. Test the patient’s ability to swallow with a
small amount of water.
Answer: 1
Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the
throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is
absent, defer the feeding, and begin exercises to stimulate swallowing. To assess swallowing ability,
elevate the head of the bed to an upright position (unless contraindicated), and give the patient a
small amount of crushed ice or ice water to swallow.
88 Answer #3
Answer: 1
Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the
throat with a tongue blade.
If a gag reflex is present, the patient will gag spontaneously.
If it is absent, defer the feeding, and begin exercises to stimulate swallowing.
To assess swallowing ability, elevate the head of the bed to an upright position (unless
contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.
89 Case Study
73-year-old man was admitted to the hospital with right-sided paresis and expressive aphasia.
He had been experiencing periods of confusion, right-sided weakness, and slurred speech for the
past several weeks.
These episodes were brief and resolved completely within an hour. No treatments were sought.
90 Case Study 1
History of COPD, MI 15 years prior, and atrial fibrillation
Over the first 24 hours of admission, his neurologic deficits gradually progressed.
By day 2 of admission, he had right-sided flaccid paralysis and global aphasia.

91 Discussion Questions Case Study
What is probably the cause of his stroke?
Could this stroke have been prevented?
With his history of atrial fibrillation, he could have had an embolic stroke. He also has risk factors for
a thrombotic stroke. He also could have been having transient ischemic attacks.
There are preventable risk factors that could have been modified, such as hypertension. The atrial
fibrillation should have been treated with anticoagulants.
92 Discussion Questions Case Study
What are the priority nursing interventions for him?
What teaching will you need to do for him and his family?
3. Preventing any complications related to immobility. Helping him adjust and cope with the results
of the stroke.
4. Discuss what changes they can expect to see as a result of the stroke. Then the focus should be on
rehabilitation.

Orem

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ASIC CONDITIONING FACTORS

Development state Ego integrity vs despair

Sociocultural orientation No formal education, Indian, Hindu

Health care system Institutional health care

Family system Married, husband working

Patterns of living At home with partner

Resources Husband, daughter, sister’s son

UNIVERSAL SELF-CARE REQUISITES

Air Breaths without difficulty, no pallor cyanosis

Elimination Voids and eliminates bowel without difficulty.

Promotion of normalcy Has good relation with daughter

DEVELOPMENTAL SELF-CARE REQUISITES

HEALTH DEVIATION SELF CARE REQUISITES

5. MEDICAL PROBLEM AND PLAN

Syp. Heamup 2tsp TID

Medical Diagnosis: Rheumatoid arthritis

Medical Treatment: Medication and physical therapy.

Maintain a developmental environment.

Prevent or manage the developmental threats

Maintenance of health status

Awareness and management of the disease process.

Adherence to the medical regimen

Awareness of potential problem.

Adjust life style to accommodate health status changes and MR

NURSING CARE PLAN ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT

Nursing diagnosis Outcome and Implementation Evaluation

Maintain a developmental environment.

Prevent or manage the developmental threats

Maintenance of health status

Awareness and management of the disease process.

Adherence to the medical regimen

Awareness of potential problem.

modify self image

. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: FOOD

ADEQUACY OF SELF CARE AGENCY: INADEQUATE

OUTCOMES AND PLAN

Maintenance of a balanced diet with adequate iron supplementation.

b. Nursing Goals and objectives

oal: to achieve optimal levels of nutrition.

Objectives: Mrs. X will:

state the importance of maintaining a balanced diet.

c. Design of the nursing system:

oal: to achieve optimal levels of nutrition.

Objectives: Mrs. X will:

state the importance of maintaining a balanced diet.

c. Design of the nursing system:

Providing developmental environment

Mrs. X understood the importance of maintaining an optimum nutrition.

The supportive educative system was useful for Mrs. X

HERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: ACTIVITY

ADEQUACY OF SELF CARE AGENCY: INADEQUATE

NURSING DIAGNOSISSelf-care deficit: dressing, toileting related to restricted joint movement,

OUTCOMES AND PLAN

b. Nursing Goals and objectives

Goal: to achieve optimal levels of ability for self care.

Objectives: Mrs. X will:

perform the dressing activities within limitations

utilize the alternative measures available for improving the toileting

perform the other activities of daily living with minimal assistance.

c. Design of the nursing system: Partly compensatory

Provide assistance whenever needed for the self care activities

4. Promoting a developmental environment:

She verbalized an improved comfort and self care ability.