Use this nursing care plan and management guide to help care for patients with cerebrovascular accident (CVA). Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals facing cerebrovascular accident (CVA).
Cerebrovascular accident (CVA), also known as stroke, acute ischemic stroke, cerebral infarction, or brain attack, is any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels of the entire cerebrovascular system. It is the sudden impairment of cerebral circulation in one or more blood vessels supplying the brain. This pathology either causes hemorrhage from a tear in the vessel wall or impairs cerebral circulation by partial or complete occlusion of the vessel lumen with transient or permanent effects. The sooner the circulation returns to normal after a stroke, the better the chances are for a full recovery. However, about half of those who survived a stroke remain disabled permanently and experience the recurrence within weeks, months, or years.
Thrombosis, embolism, and hemorrhage are the primary causes of stroke, with thrombosis being the leading cause of both CVAs and transient ischemic attacks (TIAs). The most common vessels involved are the carotid arteries and those of the vertebrobasilar system at the base of the brain.
Strokes can be divided into two types: hemorrhagic or ischemic. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery. Ischemic stroke can present in pre-determined syndromes due to the effect of decreased blood flow to particular areas of the brain that correlate to exam findings (Munakomi, 2018). Intracerebral hemorrhage (ICH) is the second most common type of stroke. ICH is typically caused by the rupture of small arteries secondary to hypertensive vasculopathy, cerebral amyloid angiopathy (CAA), coagulopathies, and other vasculopathy (Tadi & Lui, 2023).
The system of categorizing stroke developed in the multicenter Trial of ORG 10172 in Acute Stroke Treatment (TOAST) divides ischemic strokes into three major subtypes: large-artery, small-vessel, and cardioembolic infarction. Large-artery infarctions often involve thrombotic in situ occlusions on the atherosclerotic lesions in the carotid, vertebrobasilar, and cerebral arteries typically proximal to major branches. Cardiogenic emboli are a common source of recurrent strokes. They may account for up to 20% of acute strokes and have been reported to have the highest 1-month mortality. Small vessel or lacunar strokes are associated with small focal areas of ischemia due to obstruction of single small vessels, typically in deep penetrating arteries, that generate a specific vascular pathology (Jauch & Lutsep, 2022).
Stroke is the leading cause of disability and the fifth leading cause of death in the United States. According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of these, 5 million die, and another 5 million are left permanently disabled. The prognosis after acute ischemic stroke varies greatly in individual clients, depending on the stroke severity and on the client’s premorbid condition, age, and poststroke complications (Jauch & Lutsep, 2022).
The primary nursing care plan goals for clients with stroke depend on the phase of CVA the client is in. During the acute phase of CVA, efforts should focus on survival needs and prevent further complications. Care revolves around efficient continuing neurologic assessment, support of respiration, continuous monitoring of vital signs, careful positioning to avoid aspiration and contractures, management of GI problems, and monitoring of electrolyte and nutritional status. Nursing care should also include measures to prevent complications.
The following are the nursing priorities for patients with CVA:
Assess for the following subjective and objective data:
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with cerebrovascular accident (CVA) based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
Therapeutic interventions and nursing actions for patients with cerebrovascular accident (CVA) may include:
Ischemic stroke pathophysiology starts with inadequate blood supply to a focal area of brain tissue. The central core of tissue evolves toward death within minutes and is referred to as the area of infarction. More adenosine triphosphate (ATP) is consumed than produced in the area of reduced blood flow, leading to decreased energy stores, ionic imbalance, and electric disturbances. These ischemia-related changes can later lead to cell membrane destruction and cell death (Tadi & Lui, 2023).
Assess airway patency and respiratory pattern.
Neurologic deficits of a stroke may include loss of gag reflex or cough reflex; thus, airway patency and breathing pattern must be part of the initial assessment. Clients with a decreased level of consciousness should be assessed to ensure that they are able to protect their airways. Clients with stroke, especially hemorrhagic stroke, can suffer quick clinical deterioration; therefore, constant reassessment is critical (Jauch & Lutsep, 2022).
Assess factors related to decreased cerebral perfusion and the potential for increased intracranial pressure (ICP).
The extensive neurologic examination will help guide therapy and the choice of interventions. Contusions, lacerations, and deformities may suggest trauma as the etiology for the client’s symptoms. ICP elevation after a stroke compromises the perfusion of the ischemic penumbra by reducing cerebral perfusion pressure. Even an ICP elevation of 5 mm Hg above pre-stroke levels can dramatically reduce the blood flow through the collateral-supplied arterioles feeding the ischemic penumbra. This suggests that ICP elevation is probably a dominant cause of collateral failure and early neurological deterioration (McLeod et al., 2023).
Recognize the clinical manifestations of a transient ischemic attack (TIA).
Clients with TIA present with temporary neurologic symptoms such as sudden loss of motor, sensory, or visual function caused by transient ischemia to a specific region of the brain, with their brain imaging scan showing no evidence of ischemia. Recognizing symptoms of TIA may serve as a warning of an impending stroke as approximately 15% of all strokes are preceded by a TIA (Amarenco et al., 2018; Sacco, 2004). Evaluation and prompt treatment of the patient who experienced TIA can help prevent stroke and its irreversible complications.
Frequently assess and monitor neurological status.
This assesses trends in the level of consciousness (LOC), the potential for increased ICP, and helps determine the location, extent, and progression of damage. The prognosis depends on the neurologic condition of the client. It may also reveal the presence of TIA, which may warn of impending thrombotic CVA. Neurologic assessment includes a change in the level of consciousness or responsiveness, response to stimulation, orientation to time, place, and person, eye-opening, pupillary reactions to light, accommodation, and size of pupils.
Monitor changes in blood pressure, and compare BP readings in both arms.
Hypertension is a significant risk factor for stroke. Fluctuation in blood pressure may occur because of cerebral injury in the vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse), and increased ICP may occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by the difference in pressure readings between arms. Many clients with stroke are hypertensive at baseline, and their blood pressure may become more elevated after stroke. While hypertension at presentation is common, blood pressure decreases spontaneously over time in most clients (Jauch & Lutsep, 2022). Additionally, if the client is eligible for fibrinolytic therapy, blood pressure control is essential to decrease the risk of bleeding.
Monitor heart rate and rhythm, and assess for murmurs.
Changes in rate, especially bradycardia, can occur because of brain damage. Dysrhythmias and murmurs may reflect cardiac disease, precipitating CVA (stroke after MI or valve dysfunction). The presence of atrial fibrillation increases the risk of emboli formation. Strokes may occur concurrently with other acute cardiac conditions, such as acute myocardial infarction and acute heart failure; thus, auscultation for murmurs and gallops is recommended (Jauch & Lutsep, 2022).
Monitor respirations, noting patterns and rhythm, Cheyne-Stokes respiration.
Irregular respiration can suggest the location of cerebral insult or increasing ICP and the need for further intervention, including possible respiratory support. Ischemic strokes, unless large or involve the brainstem, do not tend to cause immediate problems with airway patency, breathing, or circulation compromise. On the other hand, clients with intracerebral or subarachnoid hemorrhage frequently require intervention for airway protection and ventilation (Jauch & Lutsep, 2022).
Evaluate pupils, noting size, shape, equality, and light reactivity.
Pupil reactions are regulated by the oculomotor (III) cranial nerve and help determine whether the brain stem is intact. Pupil size and equality are determined by the balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves. Studies show the development of oculomotor cranial nerve palsy was associated with an increased risk of subsequent stroke, and the risk for stroke reduced with time only after third and fourth nerve palsies, but not with sixth nerve palsy (Park et al., 2018).
Document changes in vision: reports of blurred vision, alterations in the visual field, and depth perception.
Visual disturbances may occur if the aneurysm is adjacent to the oculomotor nerve. Specific visual alterations reflect an area of the brain involved. Many clients report vision difficulties, including poor visual memory, a decrease in balance, decreased depth perception, and reading problems. Spatial inattention can result in not paying attention to the side of the body affected by stroke (American Stroke Association, 2018).
Assess higher functions, including speech, if the client is alert.
Changes in cognition and speech content indicate location and degree of cerebral involvement and may indicate deterioration or increased ICP. input from family members, coworkers, and bystanders may be required to help establish the exact time of onset, especially in right hemispheric strokes accompanied by neglect or left hemispheric strokes with aphasia (Jauch & Lutsep, 2022).
Assess for nuchal rigidity, twitching, increased restlessness, irritability, and the onset of seizure activity.
Nuchal rigidity (pain and rigidity of the back of the neck) may indicate meningeal irritation. Seizures may reflect an increase in ICP or cerebral injury requiring further evaluation and intervention. A seizure occurs in 2 to 23% of clients within the first days after an ischemic stroke. Moreover, a fraction of clients who have experienced stroke develops chronic seizure disorders (Jauch & Lutsep, 2022).
Use the National Institutes of Health Stroke Scale (NIHSS) for assessing neurologic impairment.
A useful tool in quantifying neurologic impairment is the NIHSS. The NIHSS enables the healthcare provider to rapidly determine the severity and possible location of the stroke. NIHSS scores are strongly associated with outcomes and can help to identify those clients who are likely to benefit from reperfusion therapies and those who are at higher risk of developing complications from stroke (Jauch & Lutsep, 2022).
Screen the client for stroke risk.
Risk factors for ischemic stroke include modifiable and nonmodifiable conditions. Identification of risk factors in each client can uncover clues to the cause of the stroke and the most appropriate treatment and secondary prevention plan. In a prospective study, it was found that migraine with aura was a strong risk factor for any type of stroke (Jauch & Lutsep, 2022).
Monitor blood glucose levels.
Hypoglycemia and hyperglycemia need to be identified and treated early in the evaluation. Not only can both produce symptoms that mimic ischemic stroke, but they can also aggravate ongoing neuronal ischemia (Jauch & Lutsep, 2022).
Position with head slightly elevated and in a neutral position.
This reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion. During the acute phase of stroke, maintain the head of the bed at less than 30 degrees. Because prolonged immobilization may lead to its own complications, the client should not be kept flat for longer than 24 hours. Additionally, lying flat can increase ICP (Jauch & Lutsep, 2022).
Maintain bedrest, provide a quiet and relaxing environment, and restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit the duration of procedures.
Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding. Client position, hyperventilation, and hyperosmolar therapy may be used for clients with increased ICP secondary to closed head injury. The maximum severity of cerebral edema is typically reached 72 to 96 hours after the onset of stroke (Jauch & Lutsep, 2022).
Prevent straining at stool, holding breath, and physical exertion.
Valsalva maneuver increases ICP and potentiates the risk of rebleeding. Significant cerebral edema after ischemic stroke is thought to be somewhat rare (10 to 20%). Early indicators of ischemia on presentation and on non-contrast CT are independent indicators of potential swelling and deterioration (Jauch & Lutsep, 2022).
Stress smoking cessation.
Cigarette smoking is a well-established risk factor for all forms of stroke. Smoking increases the risk of stroke by three to fourfold (Shah & Cole, 2010). Encouraging the client to quit, counseling, nicotine replacement, and oral smoking cessation medications are some approaches to aid in quitting. Nurses are the first line of treatment among hospital staff capable of planning and implementing interventions to quit smoking. Research suggests that smoking cessation counseling by nurses plays a crucial role in quitting smoking (Kazemzadeh, Manzari, & Pouresmail, 2017).
Administer supplemental oxygen as indicated.
This reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation. Supplemental oxygen is recommended when the client has a documented oxygen requirement (oxygen saturation <95%) (Jauch & Lutsep, 2022).
Administer medications and insulin as indicated.
See pharmacological interventions.
Monitor laboratory studies as indicated: prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level.
See Diagnostic and Laboratory Procedures
Prepare for surgery, as appropriate.
It may be necessary to resolve the situation and reduce neurological symptoms of recurrent stroke. Surgical management, compared to medical management alone, has been shown to decrease mortality for selected clients. Surgical options include minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration, external ventricular drain insertion, and craniotomy (Tadi & Lui, 2023).
The goal of care for clients with limited physical mobility is to maintain and improve the client’s functional abilities through maintaining normal functioning and alignment, reducing spasticity, preventing edema of extremities, and preventing complications of immobility. A stroke is a sudden ischemic or hemorrhagic episode that causes a disturbed generation and integration of neural commands from the sensorimotor areas of the cortex. As a consequence, the ability to selectively activate muscle tissues for performing movement is reduced (Villafañe et al., 2017).
Assess the extent of impairment initially and functional ability. Classify according to a 0 to 4 scale.
This identifies strengths and deficiencies that may provide information regarding recovery. This also assists in the choice of interventions because different techniques are used for flaccid and spastic paralysis. After discharge from the hospital, many clients will require continuing help with activities of daily living (ADLs), such as moving, bathing, dressing, and toileting (Pandi et al., 2017).
Monitor the lower extremities for symptoms of thrombophlebitis.
Bed rest puts patients at risk for the development of deep vein thrombosis. Unequal pulses or blood pressures in the extremities may also reflect the presence of aortic dissections. In immobilized post-stroke clients, the incidences of deep vein thrombosis (DVT) vary from 10 to 75%, depending on the diagnostic method and time of evaluation. DVt commonly occurs in the setting of a stroke and can be a fatal complication if it leads to pulmonary emboli (Ikram, 2017).
Observe the affected side for color, edema, or other signs of compromised circulation.
Edematous tissue is more easily traumatized and heals more slowly. When muscles contract, it increases the strength in pumping lymphatic vessels, allowing the fluid to move faster/ when muscles and joints become difficult to move after stroke, it impairs the flow of lymph and leads to fluid build-up in the affected tissue (Denslow, 2020).
Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary.
Pressure points over bony prominences are most at risk for decreased perfusion. Circulatory stimulation and padding help prevent skin breakdown and decubitus development. Clients who experienced a stroke may have physical impairments, such as weakness or paralysis on one side of the body. These physical limitations can affect mobility and the ability to change positions or shift weight while sitting or lying down.
Change positions at least every two hours (supine, side-lying) and possibly more often if placed on the affected side.
Frequently changing the position of the patient can reduce the risk of tissue injury. Place a pillow between the legs of the client before placing them in a side-lying position. The upper thigh should not be acutely flexed to promote venous return and prevent edema. The client may be turned from side to side if tolerated unless sensation is impaired. The amount of time spent on the affected side should be limited because of poorer circulation, reduced sensation, and more predisposition to skin breakdown. However, if the client is placed in a supine position for the long term, it may increase ICP (Jauch & Lutsep, 2022).
Position in a prone position once or twice a day if the client can tolerate it.
Monitor the client’s respiration during this position. For several 15 to 30 minutes times a day, the client should be placed in a prone position with a pillow placed under the pelvis. This position helps in normal gait through hyperextension of the hip joints and helps in preventing knee and hip flexion contractures (Crawford & Harris, 2016; Dowswell & Young, 2000). A prone position can also help drain bronchial secretions and prevents contractual deformities of the shoulders and knees.
Prop extremities in a functional position; use the footboard during the period of flaccid paralysis. Maintain a neutral position on the head.
This prevents contractures and foot drop and facilitates use when the function returns. Flaccid paralysis may interfere with the ability to support the head, whereas spastic paralysis may lead to deviation of the head to one side. Laying completely flat with a pillow between the knees or spending time lying on the stomach may help stretch the hip muscles and improve mobility after prolonged periods of sitting (Cairer, 2022).
Use an arm sling when the client is in an upright position, as indicated.
During flaccid paralysis, using a sling may reduce the risk of shoulder subluxation and shoulder-hand syndrome. An arm sling also provides support and helps hold the arm in a more comfortable position, relieving strain on the muscles and joints. The limb is also positioned in a way that allows for some functional use.
Evaluate the need for positional aids and splints during spastic paralysis.
Flexion contractures occur because flexor muscles are stronger than extensors. Orthoses include splints and props that are custom fitted to support and gently stretch the affected muscles and joints. These are often provided to address hand and wrist contractures by providing optimal positioning and light, long-duration stretch (Cairer, 2022).
Place a pillow under the axilla to abduct the arm.
When the client is in bed, place a pillow in the axilla when there is limited external rotation to keep the arm away from the chest. Place a pillow under the arm while it is in a neutral position, with the distal joints of the arm, positioned higher than the more proximal joints. This helps prevent adduction of the shoulder and flexion of the elbow. Positioning while lying on the weaker side includes one or two pillows placed under the head and the weaker shoulder positioned comfortably on a pillow (The Wright Stuff, Inc., 2023).
Elevate arm and hand
This promotes venous return and helps prevent edema formation. It is important to note that the degree and duration of elevation should be determined based on the individual’s condition and the healthcare provider’s recommendations. Too much elevation or prolonged elevation may have adverse effects, such as reduced blood flow or discomfort in other areas.
Place hard hand rolls in the palm with fingers and thumb as opposed.
Hard hand rolls decrease the stimulation of finger flexion, maintaining the finger and thumb in a functional position. If the upper extremity is spastic, a hand roll is not used because it stimulates the grasp reflex. Alternatively, place the hand with the palm facing upward, and the fingers are placed so that they are barely flexed. Every effort is made to prevent edema of the hand.
Place the knee and hip in an extended position. Maintain the leg in a neutral position with a trochanter roll.
This maintains a functional position. A trochanter roll prevents external hip rotation. When lying on the back, the stronger leg must be placed forward on one or two pillows, and the weaker leg is straight out. Muscles can be affected in various ways, causing pain, spasticity, and problems with speed and range of motion. One way to minimize these effects is to properly support, position, and align the body (The Wright Stuff, Inc., 2023).
Discontinue the use of the footboard when appropriate.
Continued use (after a change from flaccid to spastic paralysis) can cause excessive pressure on the ball of the foot, enhance spasticity, and increase plantar flexion. The prolonged stretching or stimulation of the muscles may lead to increased muscle tone and involuntary muscle contractions.
Assist the client in developing sitting and standing balance.
This aids in retraining neuronal pathways, enhancing proprioception and motor response. Assist the client by raising the head of the bed, assisting in sitting on the edge of the bed, having the client use the strong arm to support the body weight, and moving using the strong leg. Assist in developing standing balance by putting on flat walking shoes. Support the client’s lower back with hands while positioning their own knees outside the client’s knees and assist in using parallel bars.
Get the client up in a chair as soon as vital signs are stable, except following a cerebral hemorrhage.
This helps stabilize BP (by restoring vasomotor tone), promotes maintenance of extremities in a functional position, and emptying of the bladder, reducing the risk of urinary stones and infections from stasis. Following a stroke, damage to the brain and associated motor pathways inhibits purposeful muscle activation. As a result, voluntary movement of the associated limb is restricted and active motion is decreased. This means involved body parts are often less mobile after a stroke (Cairer, 2022). If a stroke is not completed, activity increases the risk of additional bleeding.
Position the client and align his extremities correctly. Use high-top sneakers to prevent foot drop, contracture, convoluted foam, flotation, or pulsating mattresses or sheepskin. Pad chair seat with foam or water-filled cushion, and assist the client to shift weight at frequent intervals.
These are measures to prevent pressure injuries. Padding the chair seats help prevent pressure on the coccyx and skin breakdown. To prevent pressure injuries, make sure that the client does not lie in the same position for a long time. Use pillows to support the affected limbs, especially the heels and elbows. Special mattresses reduce pressure and help prevent skin breakdown for clients who are unable to reposition themselves in bed (The Wright Stuff, Inc., 2023).
Provide egg-crate mattress, water bed, flotation device, or specialized beds, as indicated.
This promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and pressure injury formation. Specialized beds help with positioning, enhance circulation, and reduce venous stasis to decrease the risk of tissue injury and complications such as orthostatic pneumonia.
Begin active or passive range-of-motion (ROM) exercises on admission to all extremities (including splinted). Encourage exercises such as quadriceps/gluteal exercise, squeezing a rubber ball, and an extension of fingers and legs/feet.
Active ROM exercises maintain or improve muscle strength, minimize muscle atrophy, promote circulation, and help prevent contractures. Passive ROM exercises help maintain joint flexibility. Affected extremities are put through passive ROM exercises about five times a day to maintain joint mobility, and flexibility, prevent contractures, prevent deterioration of the neuromuscular system, enhance circulation, and regain motor control. Exercises help prevent venous stasis and decrease the risk of venous thromboembolism.
Encourage the client to assist with movement and exercises using unaffected extremities to support and move the weaker side.
The client may respond as if the affected side is no longer part of the body and needs encouragement and active training to “reincorporate” it as a part of its own body. Engaging muscles, including tight muscles, encourage improvements in range of motion and strength. Additionally, exercise helps promote neuroplasticity, or rewiring the brain, which is the primary goal of stroke rehabilitation. The more the client practices stroke exercises, the more the brain will improve the ability to correctly send motor signals to the affected muscles (Cairer, 2022).
Assist the client with exercise and perform ROM exercises for both the affected and unaffected sides. Teach and encourage the client to use his unaffected side to exercise his affected side.
Frequent repetition of activity helps form new neural pathways in the central nervous system, encouraging new patterns of motion. Initially, extremities are usually flaccid and tight; in this case, ROM exercises should be performed more frequently. Passive range of motion can be performed independently by using the non-affected side or the client may ask assistance from the nurse. Passive exercise still helps reduce stiffness and prevent complications (Cairer, 2022).
Use the “start low and go slow” approach during exercise.
Frequent short periods of exercise are always encouraged compared to more extended periods at infrequent intervals. Improvement in muscle strength and maintenance of the client’s range of motion and flexibility can only be achieved through daily exercise. It will take time to see results, but if there is consistent work, the client’s mobility can improve and increased functioning will follow (Cairer, 2022).
Monitor the client for signs and symptoms of pulmonary embolism or cardiac overload during exercise.
With exercise, shortness of breath, chest pain, cyanosis, and increased pulse rate may indicate pulmonary embolism or excessive cardiac workload. Clients should receive DVT prophylaxis, although the timing and institution of this therapy are unknown (Jauch & Lutsep, 2022).
Set goals with the client and significant other (SO) for participation in activities and position changes.
This promotes a sense of expectation for improvement and provides some sense of control and independence. Guidelines from AHA/ASA recommended that at inpatient rehabilitation facilities clients would receive at least three hours each day of specific rehabilitation tailored to their needs by a dedicated and coordinated team of professionals (Hughes, 2016).
Incorporate fall prevention strategies.
According to the AHA/ASA, once a client with a stroke or post-stroke falls and has a bad injury, the recovery is stalled and deterioration accelerates. These falls could be prevented with better education for both the client and their families. This would include advice on side effects of drug treatments that may affect balance, removing obstacles at home, the need for good lighting, and proper training on how best to use mobility aids such as walkers, wheelchairs, and canes (Hughes, 2016).
The incidence of aphasia (a language disorder that affects the ability to communicate) in acute stroke clients is about 30%. In the first weeks following onset, more than half of these clients have moderate-to-severe aphasia. The ability to communicate verbally is seriously disrupted, which is having an impact not only on the individual with aphasia but also on family, friends, and the healthcare staff (Blom-Smink et al., 2017).
Differentiate aphasia from dysarthria.
This helps determine the area and degree of brain involvement and difficulty the client has with any or all communication process steps. A stroke that occurs in areas of the brain that control speech and language can result in aphasia, a disorder that affects the ability to speak, read, write, and listen (American Stroke Association, 2018). On the other hand, dysarthria is a loss of the ability to articulate words normally. It is a problem with controlling the muscles of speech, which is a motor problem (Huang, 2021).
Assess the client for aphasia.
Aphasia is the loss of the ability to understand or express speech. The client may have receptive aphasia or damage to Wernicke’s speech area, characterized by the client using wrong or meaningless words that do not make sense. The client may also have expressive aphasia or injury to Broca speech areas, which is difficulty in forming complete sentences or trouble in understanding sentences, or may experience both (American Stroke Association, 2018). The choice of interventions depends on the type of impairment. Aphasia is a disorder in using and interpreting language symbols and may involve sensory and motor components (inability to comprehend written or spoken words or to write, make signs, or speak). The Boston Diagnostic Aphasia Examination (BDAE) is a tool that can be used to help diagnose aphasia.
Assess the client for dysarthria.
Dysarthria is a motor speech disorder in which the muscles used to produce speech are damaged, paralyzed, or weak. A dysarthric person can comprehend, read, and write language but has difficulty pronouncing words. The client may lose the ability to monitor verbal output and be unaware that communication is not sensible. Standardized tests of brain function (neuropsychological testing) may be given by a neuropsychologist or speech therapist. These tests also help healthcare professionals plan treatment and determine how likely recovery is (Huang, 2021).
Ask the client to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat simple words or sentences.
Tests for Wernicke aphasia or receptive aphasia. In Wernicke aphasia, language output is fluent with a normal rate and intonation. However, the content is often difficult to understand because of paraphrastic errors. On the bedside examination, each component of language should be tested including assessments of verbal fluency, ability to name objects, repeating simple phrases, comprehension of simple and complex commands, reading, and writing (Acharya & Wroten, 2017).
Point to objects and ask the client to name them.
These are tests for Broca aphasia or expressive aphasia. Broca aphasia is non-fluent aphasia in which the output of spontaneous speech is markedly diminished, and there is a loss of normal grammatical structure. The client may recognize an item but not be able to name it. Bedside examination of a client with suspected Broca aphasia includes assessments of fluency, the ability to name objects, repeat short phrases, follow simple and complex commands, read, and write (Acharya & Wroten, 2017).
Have the client produce simple sounds (“dog,” “meow,” “Shh”).
This test 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. Clients with dysarthria produce sounds that approximate what they mean and that are in the correct order. However, the speech may be jerky, staccato, breathy, irregular, imprecise, or monotonous, depending on where the damage is (Huang, 2021).
Assess the client for signs of depression.
A client with aphasia may become depressed. The inability to talk, communicate, and participate in a conversation can often cause frustration, anger, and hopelessness. It is important to address issues of post-stroke depression and post-stroke cognitive impairment to optimize the outcome for the client. Clients with Broca aphasia are often very upset about their difficulty communicating. This may be due to the deficit itself or may be due to damage to adjacent frontal lobe structures which control the inhibition of negative emotions (Acharya & Wroten, 2023). Make the atmosphere conducive to communication and be sensitive to the client’s reactions and needs. The nurse can provide vital emotional support and understanding to allay anxiety and frustration.
Differentiate the client’s symptoms from Alzheimer dementia symptoms.
Wernicke aphasia must be distinguished from Alzheimer dementia. In both cases, the client may have trouble answering basic orientation questions. In Wernicke aphasia, the key deficit is comprehension, whereas, with dementia, the problem is with memory. Alzheimer disease tends to be subacute in onset and progressive in nature as opposed to Wernicke aphasia which is sudden in onset due to ischemic stroke (Acharya & Wroten, 2022).
Listen for errors in conversation and provide feedback.
Feedback helps clients realize why caregivers are not understanding or responding appropriately and provide an opportunity to clarify meaning. The presence of a strong relationship, one in which the client felt understood and supported, and where they felt they could trust the healthcare professional, could provide safety and security that could alleviate the emotional distress (Bright & Reeves, 2022).
Ask the client to write their name and a short sentence. If unable to write, have the client read a short sentence.
Tests for writing disability (agraphia) and deficits in reading comprehension (alexia) are also part of receptive and expressive aphasia. Associated neurological symptoms depend on the size and location of the lesion and include visual field deficits, trouble with calculation (acalculia), and writing. In some cases, there is an impairment in reading. Even when they are able to write fluently, the choice of words and spelling is abnormal. An early clue to Wernicke aphasia is abnormal spelling (Acharya & Wroten, 2022).
Write a notice at the nurses’ station and the client’s room about speech impairment. Provide a special call bell that can be activated with minimal pressure if necessary. Anticipate and provide for the client’s needs.
This allays anxiety related to the inability to communicate and fear that needs will not be met promptly. Clients placed importance on being seen and feeling heard by the staff, that is, sensing the healthcare professionals had a good understanding of who they are and what they are going through, and were responding to this, individualizing their interactions and subsequent healthcare (Bright & Reeves, 2022).
Provide alternative methods of communication.
A communication board that has pictures of common needs and phrases may help the client. This provides a method of communicating needs based on the individual situation and underlying deficit. Augmentative and alternative communication (AAC) systems were introduced into clinical practice to help compensate for persistent language deficits and communication problems. The Visual Scene Display (VSD) was used to enhance communication through a traditional grid display which employs personally relevant photographs and related text as well as speech output placed on the VSD device. Participants perceived the personally relevant photographs and the text as helpful during conversations (Russo et al., 2017).
Talk directly to the client, speaking slowly and distinctly. Gain the client’s attention when speaking. Phrase questions to be answered simply by yes or no. Progress in complexity as the client responds.
This reduces confusion and allays anxiety at having to process and respond to a large amount of information at one time. Keep the language of instruction consistent and speak slowly. As speech retraining progresses, advancing the complexity of communication stimulates memory and further enhances word and idea association. Avoid completing the thoughts or sentences of the client because it can make the client more frustrated by not being able to speak and may deter efforts to practice putting thoughts together and completing sentences.
Speak in normal tones and avoid talking too fast. Give the client ample time to respond. Avoid pressing for a response. Use gestures to enhance comprehension. Avoid “speaking down” to the client or making patronizing remarks.
The client is not necessarily hearing impaired, and raising a voice may irritate or anger the client causing frustration. Forcing responses can result in frustration and may cause clients to resort to “automatic” speech (garbled speech, obscenities). Allow the client ample time to process instructions and provide an environment for the client to feel esteemed because intellectual abilities often remain intact. Be patient with the client. Positive interactions, in which clients felt they had a voice and that the voice was heard, were important in supporting adjustment and well-being. This gives a sense of being seen as an individual, as someone who has value, competence, and intelligence, and whose needs, emotions, and perspectives are important (Bright & Reeves, 2022).
Discuss familiar topics (e.g., weather, family, hobbies, jobs).
This promotes meaningful conversation and provides an opportunity to practice skills. Communicating during nursing care activities can also provide a form of social therapy to the client. It is important that interactions are conversational and somewhat “natural” and authentic with a sense of flow and interaction throughout the exchanges, a sense of a living dialogue that was threaded through and across interactions. Communication is key to sustaining relationships over time (Bright & Reeves, 2022).
Encourage significant others (SO) to continue communicating with the client: reading mail and discussing family happenings even if the client cannot respond appropriately.
Family members need to continue talking to clients to reduce the client’s isolation, promote effective communication, and maintain a sense of connectedness with the family. Family and social support are extremely important to keep clients with language deficits engaged in social and leisure activities which can greatly influence the aphasic client’s quality of life (Acharya & Wroten, 2023).
Eliminate extraneous noise and stimuli as necessary.
When communicating with the client, it is important to eliminate background noise and distractions, maintain eye contact, and keep the voice at a normal volume and rate (Acharya & Wroten, 2022). This reduces anxiety and exaggerated emotional responses and the confusion associated with sensory overload.
Consult and refer the client to a speech therapist.
A speech therapist can help assess the communication needs of the client, identify specific deficits, and recommend an overall method of communication. Encourage the client to play an active part in establishing goals so that language intervention strategies are individualized to their needs. A care plan developed with a speech therapist, neuropsychologist, and neurologist would be the best way to try to optimize client outcomes. The treatment plan aims to allow the client to better use the remaining language functions, improve language skills, and communicate in alternative ways so that their wants and needs can be addressed (Acharya & Wroten, 2022).
Arrange for participation in group, speech, and language therapy, as indicated.
Group therapy can give the client a chance to practice their communication skills and may lead to decreased feelings of social isolation (Acharya & Wroten, 2022). Speech and language therapy is the mainstay of care for clients with aphasia. The timing and nature of the interventions for aphasia vary widely. Clients’ difficulties vary, and individualized programs are often important (Kirshner & Chawla, 2023).
Provide information about other treatment options, such as melodic intonation.
Melodic intonation is an innovative treatment option for clients with Broca aphasia which relies on the fact that musical ability is often spared in Broca aphasia. Thus, the speech therapist encourages the client with poor speech production to try to express their words with musical tones. This approach has shown promise in clinical trials (Acharya & Wroten, 2023).
Post-stroke pain is common and can affect the rehabilitation and quality of life of stroke survivors. Pain after stroke is often under-reported, being diagnosed only if actively searched by the clinician. Musculoskeletal pain appears to be the most common being reported in up to 72% of clients with stroke. Pain after a stroke can remarkably reduce the quality of life, causing depression, anxiety, and sleep disorders making rehabilitation more difficult (Scuteri et al., 2020).
Assess the client for shoulder stiffness and pain.
Hemiplegic shoulder pain (HSP) is a common and distressing complication related to stroke and occurs in the paralytic side of the client. The prevalence of shoulder pain following a stroke was previously estimated to be 25% to 50%. The altered movement patterns of clients at certain stages of motor recovery post-stroke have been linked to shoulder pain. There is also mounting evidence for neuropathic pain mechanisms in HSP as lower pain thresholds and higher rates of allodynia and hyperpathia have been demonstrated (Plecash et al., 2019). Shoulder pain may prevent clients from learning new skills and affect their rehabilitation and quality of life post-stroke.
Assess the client for central poststroke pain (CPSP) syndrome.
HSP is linked to central poststroke pain, which is defined as pain and sensory abnormalities in the body parts that correspond to the brain territory that has been injured by the cerebrovascular lesion. CPSP may be spontaneous or can be evoked by nociceptive or normioceptic stimuli. CPSP develops about three to six months after a stroke; however, latencies ranging from within a week to several years following the stroke are reported (Plecash et al., 2019).
Assess for possible risk factors that contribute to the client’s pain.
A number of demographic and clinical characteristics are risk factors for post-stroke pain. The female sex is an independent risk factor for the development of post-stroke pain syndrome. Although older age at stroke onset is associated with the development of any pain syndrome, younger clients are at increased risk for CPSP in particular. Premorbid peripheral vascular disease and alcohol and statin use prior to the stroke, as well as a history of depression, predict the likelihood of developing any post-stroke pain syndrome (Plecash et al., 2019).
Assess for the presence of post-stroke headaches.
Persistent post-stroke headache has been recently defined as a headache occurring around stroke onset that persists for more than three months. Persistent post-stroke headache affects 23% of clients with risk factors including younger age, female sex, and the presence of pre-stroke primary headache disorder. Those with unexpected worsening focal deficits or new focal deficits and headaches warrant repeat neuroimaging (Plecash et al., 2019).
Recognize the need for a properly worn sling or orthoses.
Strapping of the hemiplegic shoulder prevents it from dangling without support by inhibiting the musculature surrounding the scapula and promoting normal alignment of the scapula in relation to the thorax, humerus, and clavicle. Though there is little evidence to confirm the benefit of strapping the shoulder in treating HSP, these techniques are used for subluxation and shoulder pain. A recent systematic review found that shoulder orthoses reduce the subluxation, but only while they are worn, and orthoses with both proximal and distal attachments were most effective (Plecash et al., 2019).
Assist the client when changing position.
Never lift the client by the flaccid shoulder or pull on the affected arm or shoulder as this will cause pain. Using an appropriate force when turning or changing the client’s position will prevent it from overstretching the affected shoulder joint. Strenuous arm and shoulder movement should also be avoided. During this period, the affected extremity should be adequately supported; the arm’s weight may be enough to cause subluxation (Physiopedia, 2022).
Position the shoulder of the client appropriately.
Many shoulder problems can be prevented by proper client movement and positioning. The position of the shoulder should be checked when the client is assisted in moving in bed, and it should be ensured that the scapula glides forward, particularly when lying on the hemiplegic side (Li & Alexander, 2015). Glenohumeral subluxation may occur as a result of adopting incorrect sleeping postures, lack of support when the client is in a vertical position, or tension on the hemiplegic arm when the client is being moved from one place to another (Physiopedia, 2022).
When lifting the arm, it should be moved slowly and rotated outward.
This avoids impingement. If the arm is paralyzed, incomplete dislocation (subluxation) at the shoulder can occur due to overstretching of the joint capsule and musculature by the force of gravity when the client sits or stands in the early stages after a stroke. Elevate the arm and hand to prevent dependent edema. Lap trays, pillows, and foam support help keep the arm and shoulder supported in the correct position (Physiopedia, 2022).
Avoid the use of overhead pulleys. Use a shoulder sling for support.
Pulling on the hemiplegic arm can contribute to subluxation. Studies have shown the effectiveness of slings in relation to the duration of their use. Supports from slings have various purposes: realigning scapular symmetry, supporting the forearm in a flexed arm position, improving anatomic alignment with auxiliary support, or supporting the shoulder with a cuff (Physiopedia, 2022).
Perform the therapeutic technique of range of movement by holding the humerus under the axilla and maintaining external rotation.
Incorrect handling of clients can cause improper dynamic motor control and rotator cuff tearing. In the early rehabilitation phase, passive range of motion (ROM) exercises have been shown to effectively prevent shoulder subluxation among stroke clients. ROM exercises for the shoulder joint include flexion-extension, abduction-adduction, and external-internal rotation. However, if these exercises are improperly carried out, they can cause injury to the shoulder and increase the client’s risk for shoulder subluxation (Physiopedia, 2022).
Assist the client in performing range-of-motion exercises.
ROM exercises are essential in preventing shoulder stiffness, thus preventing pain. Some activities the client can do include interlacing the fingers, placing the palms together, and pushing the clasp hands slowly forward to bring the scapulae forward, then raising both hands above the head; flexing the affected wrist at intervals and moving all joints of the affected fingers; and pushing the heel of the hand firmly down on a flat surface.
Administer botulinum toxin A (BTX-A) as indicated.
Studies have shown that the administration of BTX-A provided greater analgesic effects and increased shoulder abduction and external rotation ROM compared with steroids (Xie et al., 2021). Botulinum toxin can be injected into the subscapularis and pectoralis major, which are the two most common spastic muscles implicated in HSP. A Cochrane systematic review found that a single intramuscular injection of botulinum toxin significantly reduced HSP at three and six months post-injection (Plecash et al., 2019).
Administer oral pain medications as prescribed.
The medications that are helpful in the management of poststroke pain include amitriptyline, gabapentin, pregabalin, and lamotrigine. Lamotrigine has better evidence in CPSP specifically, with one small placebo-controlled double-cross-over trial of 30 clients finding a significant reduction in pain scores at 200 mg/day. Tramadol may be an effective adjunct in clients who do not respond to the first-line medications for CPSP.
Administer topical pain medications as indicated.
Various topical medications, such as amitriptyline, ketamine, lidocaine, and capsaicin, are used in localized neuropathic pain. Given the reduced side effect profile of topical as compared with systemic therapies, this is an area that would benefit from future studies (Plecash et al., 2019).
Promote the benefits of exercise intervention programs.
Exercise interventions in stroke survivors have been shown to have a beneficial role in addressing the challenges associated with pain after stroke, including mobility, fatigue, and self-efficacy. Exercise interventions also provide opportunities for social participation and peer interactions, which are associated with improved self-management in chronic pain populations (Plecash et al., 2019).
Educate the family members or caregivers about the proper positioning and handling of the client’s affected areas.
Caregivers or family members need to be informed about the importance of proper handling of the affected arm. Clients who experienced a stroke and who have their arms unsupported and/or handled inappropriately by caregivers are at a higher risk for traction neuropathy and injury. Hence, caregivers of stroke survivors must be adequately trained in handling the hemiplegic arm, especially when shoulder subluxation is present.
Teach the client and family members about shoulder strapping.
Shoulder strapping is helpful in the first period after a stroke. Shoulder strapping is used clinically in clients with a stroke, with various techniques being employed. However, a study brought out two main trends emerging from the literature. The longitudinal strapping method involves two to three strips of strapping applied with a cephalad tension over the anterior, middle, and posterior deltoid to end over the shoulder complex, sometimes with an anchor strip applied. The circumferential strapping method is the application of strapping around the shoulder joint. It originates from the clavicle, wrapping around the deltoid to go under the axilla and ending on the spine of the scapula (Physiopedia, 2022).
Provide instructions about the Bobath method.
One of the common therapeutic techniques is the Bobath. The method is centered on the idea that the client should be moved and positioned into reflex-inhibiting positions; the hemiparetic limb should be away from abnormal increases in muscle tone (Physiopedia, 2022).
Prepare the client for neuromuscular electrical stimulation (NMES).
NMES has been proposed to reduce subluxation by contracting and strengthening the supraspinatus and posterior fibers of the deltoid, which are important muscles for glenohumeral stabilization. Two systematic reviews and meta-analyses reached similar conclusions: NMES was effective at reducing shoulder subluxation in the early post-stroke (less than six months), but not the late post-stroke period (Plecash et al., 2019).
Physical, social, and cognitive impairment following a stroke may constitute a serious problem to the quality of life. An important psychosocial factor that influences the quality of life after stroke is the coping style, used by individuals to deal with the disease state. Coping strategies are determinants of the health-related quality of life after a stroke since they affect both recovery and adaptation to disability (La Buono et al., 2016).
Assess the extent of altered perception and related degree of disability. Determine Functional Independence Measure score.
Determination of individual factors aids in developing a plan of care/choice of interventions and discharge expectations. One useful way to estimate the level of functional independence in CVA clients is the evaluation of the activities of daily living (ADLs). A valid tool in this field is the Functional Independence Measure (FIM). It is a tool for the collection and comparison of rehabilitation outcomes, measurement of clients’ progress, and planning of treatment protocols. The producers planned it for a more precise evaluation of the client’s functional status, at different stages of the disease (Rayegani et al., 2016).
Identify the meaning of the dysfunction and change to the client. Note the ability to understand events, and provide a realistic appraisal of the situation.
Independence is highly valued in American culture but is not as significant in some cultures. Some clients accept and manage altered function effectively with some adjustment, whereas others may have considerable difficulty recognizing and adjusting to deficits. To provide meaningful support and appropriate problem-solving, healthcare providers need to understand the meaning of the stroke/limitations to clients.
Determine outside stressors: family, work, and future healthcare needs.
This help identifies specific needs, provides an opportunity to offer information and begin problem-solving. Consideration of social factors and functional status is vital in determining an appropriate discharge destination. In stroke survivors from the Framingham Heart Study, 31% needed help caring for themselves, 20% needed help when walking, and 71% had impaired vocational capacity in long-term follow-up (Jauch & Lutsep, 2022).
Identify previous methods of dealing with life problems. Determine the presence of support systems.
This provides an opportunity to use behaviors previously effectively, build on past successes, and mobilize resources. Active coping strategies were associated with social support and influenced emotional aspects. The support obtained from family members was a resource that helps the client with disease management (Lo Buono et al., 2016).
Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, and withdrawal.
This may indicate the onset of depression (a common after-effect of stroke), which may require further evaluation and intervention. Stroke can profoundly impair the psychosocial health of stroke survivors and their carers. Around 30% of stroke survivors are estimated to experience depression. A further 68% of carers experience depression and/or anxiety, which in turn, impacts the quality of life (Minshall et al., 2019).
Note whether the client refers to the affected side as “it” or denies the affected side and says it is “dead.”
This suggests rejection of body parts and negative feelings about body image and abilities, indicating the need for intervention and emotional support. In clients with an acute stroke that occurred>six months previously, 85% have upper-limb disorders. The upper-limb movement function is decreased due to the weakening of upper-limb muscles, which is primarily caused by changes in the central nervous system and secondarily by weakness due to inactivity and reduced activity (Choi et al., 2019).
Provide psychological support and set realistic short-term goals. Involve the client’s SO in the plan of care when possible and explain his deficits and strengths.
This is to increase the client’s sense of confidence and can help in compliance with the therapeutic regimen. The multifaceted nature of what the participants in a study perceived to be psychological support was reflected in their dialog about the importance of communication, information provision, peer, and social support. Increased recognition of the importance of protective factors, perceived to reduce the need for formal psychological support, might enable resources to be targeted at those without protective factors (Harrison et al., 2017).
Encourage the client to express feelings, including hostility or anger, denial, depression, sense of disconnectedness.
This demonstrates acceptance of the client in recognizing and beginning to deal with these feelings. In particular, social support received and the acceptance of a change of life seem to have a greater impact on the perception of individual well-being. The use of emotional-focused coping, which refers to the ability to regulate negative emotions, or accommodative coping, which is directed to a change in the personal goal standards in accordance with perceived deficits, may help the client cope with the changes in their quality of life (Lo Buono et al., 2016).
Acknowledge the statement of feelings about the betrayal of the body; remain matter-of-fact about the reality that the client can still use the unaffected side and learn to control the affected side. Use words (weak, affected, right-left) that incorporate that side as part of the whole body.
This helps the client see that the nurse accepts both sides as part of the whole individual and allows the client to feel hopeful and begin to accept the current situation. The findings in a study showed that hospital-based peer support groups for stroke clients and carers brought therapeutic gains and perceived benefits including information, advice, making connections, and downward social comparison (Harrison et al., 2017).
Emphasize small gains either in the recovery of function or independence.
This consolidates gains, helps reduce feelings of anger and helplessness, and conveys a sense of progress. Using a flexible or accommodative coping style was associated with a higher QoL and better global well-being was registered after five months after the acute event. Accommodative coping involves flexibly adjusting one’s goals in response to a persistent problem. The use of these strategies helped clients to adjust their goals to accommodate constraints and impairments by revising values and priorities, constructing new meaning from the situation, and potentially transforming personal identity (Lo Buono et al., 2016).
Support behaviors and efforts such as increased interest/participation in rehabilitation activities.
This suggests possible adaptation to changes and understanding about own role in future lifestyle. Optimal rehabilitation is essential to support an independent and meaningful life for stroke survivors. Approximately 80% of all stroke survivors are discharged to their homes following their hospital admission, with a significant number having disabilities so severe that they are dependent on practical and emotional help and support (Lou et al., 2017).
Refer for neuropsychological evaluation and counseling if indicated.
This may facilitate adaptation to role changes necessary for a sense of feeling/being a productive person. Note: Depression is common in stroke survivors and may directly result from brain damage and an emotional reaction to sudden-onset disability. Psychological expertise is a vital component of the multidisciplinary stroke team for the assessment and treatment of all aspects of psychological health, including mood disorders and cognitive impairment (Harrison et al., 2017).
Promote the use of positive coping strategies.
Active coping strategies, whether behavioral or emotional, could be good strategies to deal with stressful events. A positive association between responses designed to change the nature of the stressor and improvement of daily life activity was found after one year. Furthermore, both accommodative coping and active coping were related to a decrease in depressive symptoms (Lo Buono et al., 2016).
Prepare the client for mirror therapy.
Mirror therapy for clients with stroke was reported to be effective in improving upper extremity motor function and daily life performance. This intervention may be used to increase the use of paralyzed limbs to overcome disuse syndromes, observe and imitate movement, and change the neural network involved in the movement (Choi et al., 2019).
Provide information about peer support groups.
Peer and social support play a vital role in post-stroke psychological adjustment. Volunteer or family member-led peer support groups could be a mechanism by which social and peer support could be facilitated post-stroke, particularly in those clients experiencing “low level” psychological needs (Harrison et al., 2017).
Provide hospital staff with resources to improve psychological management knowledge about post-stroke rehabilitation.
Getting the right information about stroke was often of great importance to clients and family members and aided the processes of reassurance and adjustment. The Stroke Specific Education Framework, for example, provides the hospital staff with information about competencies required for specific disciplines and endorsed training courses and materials for providing psychological screening, assessment, and support. These resources could be utilized by non-psychology staff working on stroke units, in order to increase the capacity of stroke services to provide basic psychological support (Harrison et al., 2017).
Educate the client and family members adequately and accurately about what to expect during post-stroke rehabilitation.
The desire for information as a resource for empowerment and psychological adjustment has been found in many different conditions and is supported by a recent systematic review which demonstrated that information provision post-stroke reduced client depression. Thus, improving information provision could play a role in reducing the need for more formal psychological support post-stroke (Harrison et al., 2017).
Stroke can impact different aspects of a client’s life, including gross and fine motor control, mobility, activities of daily living (ADLs), mood, speech, comprehension, and cognition. Postural disorders, sensory and motor deficits, hemiplegia or hemiparesis, cognition and comprehension difficulties, memory impairment, decreased self-care, and ADL abilities, emotional and mood disorders, sexual dysfunction, and decreased social participation are some typical consequences of stroke. These complications directly affect the client’s role fulfillment, and finally lead to decreased client’s quality of life (Rayegani et al., 2016).
Assess abilities and level of deficit (0 to 4 scale) for performing ADLs.
This aids in planning for meeting individual needs. A valid tool in estimating the client’s level of functional independence is the Functional Independence Measure (FIM). ADLs, which are the purpose of this test include self-care, eating, grooming, bathing, dressing, toileting, swallowing, sphincter control, mobility, transfer, and locomotion (Rayegani et al., 2016).
Assess the client’s ability to communicate the need to void and the ability to use a urinal bedpan. Take the client to the bathroom at periodic intervals for voiding if appropriate.
The client may have a neurogenic bladder, be inattentive, or be unable to communicate needs in the acute recovery phase, but usually can regain independent control of this function as recovery progresses. Approximately one-third of clients with acute stroke have clinical features of aphasia. Language function in many of these clients improves, and, at six months or more after stroke, only 12% to 18% of clients have identifiable aphasia (Bruno & Kishner, 2021).
Identify previous bowel habits and reestablish a normal regimen. Increase bulk in diet, encourage fluid intake, and increased activity.
This assists in developing a retraining program (independence) and aids in preventing constipation and impaction (long-term effects). There is a growing awareness of the link between the gut and cardiovascular disease. Brain injuries, particularly stroke, have been well-established as a cause of gastrointestinal disorders. The brain-gut axis relates primarily to the association between neurology and the gastrointestinal system (Li et al., 2017).
Avoid doing things for the client that the client can do for themself, but assist as necessary.
This is to maintain self-esteem and promote recovery, the client needs to do as much as possible for themself. These clients may become fearful and dependent, although assistance helps prevent frustration. Engagement is identified as necessary for adaptation and recovery. Engaging in activities helps the client feel a sense of belonging after the stroke, obtain a sense of purpose, and regain autonomy, independence, and confidence (Lou et al., 2017).
Be aware of impulsive actions suggestive of impaired judgment.
This may indicate the need for additional interventions and supervision to promote client safety. Individuals with lesions in the prefrontal cortex due to stroke have impairment in the decision-making and processing of time intervals, which is accompanied by evidence suggesting dysfunctional connectivity between encephalic areas (Marinho et al., 2019).
Maintain a supportive, firm attitude. Allow the client sufficient time to accomplish tasks. Don’t rush the client.
Clients need empathy and to know caregivers will be consistent in their assistance. Difficulty with perceiving one’s body space is observed. This leads to difficulty in performing toileting and personal appearance activities such as the impaired ability to wash or dry the body, put on shoes, fasten clothes, maintain a personal appearance, use assistive devices to get dressed or use zippers (Oliveira-Kumakura et al., 2019).
Provide positive feedback for efforts and accomplishments.
This enhances the sense of self-worth, promotes independence, and encourages the client to continue endeavors. Several studies have demonstrated that engagement is co-constructed through relationships; with the “development of a positive connection” critical in supporting people to engage in rehabilitation. A positive relationship could give a person encouragement that could help them engage and have the courage and confidence to try (Bright & Reeves, 2022).
Create a plan for visual deficits that are present.
Place food and utensils on the tray related to the client’s unaffected side; situate the bed, so that the client’s unaffected side is facing the room with the affected side to the wall; position furniture against the wall/out of the travel path. The client will be able to see to eat the food and will be able to see when getting in/out of bed and observe anyone who comes into the room. This provides safety when the client can move around the room, reducing the 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 bags for catheters, and shower chairs. Encourage good grooming and makeup habits.
This is to enable the client to manage for self, enhance independence and self-esteem, reduce reliance on others for meeting own needs, and enable the client to be more socially active. Self-help devices can be defined as any item, piece of equipment, software program, or system that is used to increase, maintain and improve the functionality of people with any type of disability. Studies suggest the efficacy of self-help devices in improving upper limb motor function, gait, and aphasia after a stroke episode (Tatmatsu-Rocha et al., 2020).
Encourage SO to allow the client to do self-care as much as possible.
This re-establishes a sense of independence and fosters self-worth and enhances the rehabilitation process. Note: This may be very difficult and frustrating for the caregiver, depending on the degree of disability and time required for the client to complete an activity. The presence of a relationship could be a critical factor in helping people move from simply “tolerating” therapy to being engaged, serving as a source of motivation (Bright & Reeves, 2022).
Teach the client to comb hair, dress, and wash.
This is to promote a sense of independence and self-esteem. International stroke guidelines have recommended that “All clients should be offered training in self-management skills, including active problem-solving and individual goal setting”. Thus, in recent years, self-management has become part of the stroke care pathway, since it could support individuals facing the long-term consequences of stroke, and thus it could facilitate interventions related to transitional care (Fugazzaro et al., 2020).
Refer the client to a physical and occupational therapist.
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. Reports of the levels of functional independence eventually reached by stroke clients after recovery varies from one to another. In most reports, 47% to 76% of clients achieve partial or total independence in the performance of ADLs (Bruno & Kishner, 2021).
Educate the client and family members about the importance of self-management.
Studies have underlined that stroke survivors and their caregivers often feel unprepared to face the transition from hospital to community. An educational intervention for stroke clients was developed to improve self-management and foster transition from hospital to community, the Look After Yourself (LAY) program. The LAY intervention is a structured self-management program directed toward stroke survivors and includes the five self-management skills described by Lorig and Holman: problem-solving, decision-making, appropriate resource utilization, partnership with healthcare professionals, and implementation of actions necessary to manage health issues autonomously (Fugazzaro et al., 2020).
Refer the client for physical therapy.
Rehabilitation should include physical therapy that is directed at specific training of skills and at functional training. Therapy should be given with sufficient intensity to promote skill acquisition. Traditional therapy employs range-of-motion, strengthening, mobilization, and compensatory techniques. The process of mental practice may also be used to improve the performance of certain activities (Bruno & Kishner, 2021).
Stroke can often cause dysphagia due to impaired function of the mouth, tongue, and larynx. Dysphagia is associated with increased morbidity and mortality in acute stroke clients because of malnutrition, dehydration, and aspiration pneumonia. Early identification and treatment of clients at risk can improve the outcome (Suntrup-Krueger et al., 2017).
Review individual pathology and ability to swallow, noting the extent of the paralysis: clarity of speech, tongue involvement, ability to protect the airway, episodes of coughing, and presence of adventitious breath sounds.
Assess the client’s ability to swallow as soon as possible and before any oral intake. Nutritional interventions and choices of feeding routes are determined by these factors. A useful tool in dysphagia assessment is the National Institutes of Health Stroke Scale (NIHSS), which determines the severity and possible location of a stroke and if a severe neurological deficit is present (Jauch & Lutsep, 2022).
Maintain accurate I&O; record calorie count.
Alternative feeding methods may be used if swallowing efforts are not sufficient to meet fluid and nutritional needs. Nutritional status is an important issue in clients with acute stroke. It has been reported that 8.2 to 49% of stroke clients have low nutritional status. Many clients with acute stroke remain on tube feeding at the time of discharge and cannot be transferred to oral nutrition. In the past, approximately half of the clients admitted to acute care wards were reported to be undernourished. Modified food for dysphagia, such as paste diets, have lower calories per unit volume than regular diets and therefore are reported to be insufficient to provide good nutrition (Aoyagi et al., 2021).
Weigh periodically and monitor body mass index (BMI) as indicated.
Weight loss after stroke may be caused by a global negative caloric intake and, in turn, may cause an aggravation of sarcopenia that occurs because of paresis and reduced physical activity. Results of a study also showed that an increase in BMI was related to better recovery, supporting the possibility that BMI improvement may positively enhance recovery in terms of autonomy in ADLs (Morone et al., 2019).
Have suction equipment available at the bedside, especially during early feeding efforts.
Timely intervention may limit the untoward effects of aspiration. Aspiration pneumonia and respiratory-related diseases are the second most common complication after urinary tract infection in clients with acute stroke and can have a negative impact on subsequent outcomes. The pathogenesis of aspiration pneumonia is related to aspiration of saliva with poor oral hygiene, aspiration of food residue due to poor swallowing function and coughing, and compromised immunity (Aoyagi et al., 2021).
Promote effective swallowing: schedule activities and medications to provide a minimum of 30 minutes of rest before eating.
This promotes optimal muscle function and helps to limit fatigue. Dysphagia can cause fatigue due to the increased effort required to chew and swallow food. Resting provides an opportunity for the muscles involved in swallowing to recover and regain their strength. Dysphagia can disrupt the coordination of the muscles involved in swallowing, leading to difficulties in moving food from the mouth to the stomach.
Provide a pleasant and unhurried environment free of distractions.
This promotes relaxation and allows the client to focus on the task of eating. A pleasant environment, with soothing colors, comfortable seating, and a calm atmosphere, can help alleviate the client’s anxiety and stress due to dysphagia. The environment can also stimulate the client’s appetite and make them more receptive to eating.
Assist the client with head control and position based on specific dysfunction.
Counteracts hyperextension, aiding in the prevention of aspiration and enhancing the ability to swallow. Optimal positioning can facilitate intake and reduce the risk of aspiration head back for decreased posterior propulsion of the tongue, head turned to the weak side for unilateral pharyngeal paralysis, and lying down on either side for reduced pharyngeal contraction. An environment that promotes proper posture and positioning can improve the efficiency and safety of swallowing, reducing the risk of complications.
Place the client in an upright position during and after feeding as appropriate.
This is to reduce the risk of aspiration by the use of gravity to facilitate swallowing. Have the client sit upright and tuck the chin towards the chest as they swallow. Comfortable and supportive chairs or specialized seating devices can help the client maintain an upright posture, which is essential for optimal swallowing function.
Provide oral care based on individual needs before a meal.
Clients with dry mouths require moisturizing agents like alcohol-free mouthwashes before and after eating. Clients with excessive saliva will benefit from the use of drying agents before meals and moisturizing agents afterward. Deterioration of oral health and dysphagia can affect the development of aspiration pneumonia, the establishment of oral intake, and the client’s quality of life; therefore, appropriate treatment of oral health from the acute phase is required for clients with stroke (Aoyagi et al., 2021).
Serve foods at normal temperature, and water is always chilled.
Lukewarm temperatures are less likely to stimulate salivation, so foods and fluids should be served cold or warm as appropriate. Water is the most difficult to swallow. When cold water is consumed, it stimulates the temperature receptors in the oral cavity. This can activate salivary glands, leading to an increase in saliva production. Warm water can also stimulate salivation, although its effect may be milder compared to cold water.
Stimulate lips to close or manually open the mouth by light pressure on the lips or under the chin if needed.
This aids in sensory retraining and promotes muscular control. The nurse may also use an oral device, such as the Muppy oral device, which was used to measure lip force with a newton meter, and the study showed a significant difference in lip force between healthy subjects and stroke-affected clients with swallowing dysfunction. Lip force and swallowing function are shown to depend on the same complex neuromuscular activity that initiates a swallow that is activated when lip force is measured (Hägglund et al., 2020).
Place food of appropriate consistency on the unaffected side of the mouth.
This provides sensory stimulation (including taste), increasing salivation and triggering swallowing efforts, enhancing intake. Food consistency is determined by the individual deficit. For example, clients with decreased range of tongue motion require thick liquids initially, progressing to thin liquids, whereas clients with delayed pharyngeal swallow will handle thick liquids and thicker foods better. Note: Pureed food is not recommended because clients may not recognize what is being eaten, and most milk products, peanut butter, syrup, and bananas are avoided because they produce mucus and are sticky.
Touch parts of the cheek with a tongue blade and apply ice to the weak tongue.
It can improve tongue movement and control (necessary for swallowing) and inhibits tongue protrusion. Tongue pressure plays a role in bolus formation and transport processes in the oral phase of normal deglutition. Mid to median tongue pressure is an important factor in the bolus transport, especially during the ingestion of semi-solid foods (MinChun, 2021).
Feed slowly, allowing 30 to 45 minutes for meals.
Feeling rushed can increase stress and frustration, may increase the risk of aspiration, and may result in the client’s terminating the meal early. A sense of relaxation during meals and reduced stress can contribute to improved swallowing function by allowing the client to focus on the meal without distractions.
Offer solid foods and liquids at different times.
It prevents the client from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after the client has finished eating solid foods. The transition from consuming solid food to liquid helps clear any residual food particles in the mouth and throat, reducing the risk of aspiration or choking. Additionally, alternating between different textures and consistencies provides varied sensory stimulation during the meal.
Limit or avoid the use of drinking straws for liquids.
Although use may strengthen facial and swallowing muscles, if the client lacks tight lip closure to accommodate the straw or if the liquid is deposited too far back in the mouth, the aspiration risk may increase. Straws allow liquid to flow rapidly into the mouth, potentially overwhelming the swallowing mechanism. This can lead to aspiration pneumonia and other respiratory complications.
Encourage SO to bring their favorite foods. Season food with herbs, spices, lemon juice, etc., according to the client’s preference, within dietary restrictions.
This provides familiar tastes and preferences, stimulates feeding efforts, and may enhance swallowing or intake. Bringing the client’s favorite foods helps maintain their motivation to eat and comply with their dietary recommendations. It can provide a sense of comfort, familiarity, and pleasure during meals, making the eating experience more enjoyable and satisfying.
Encourage participation in an exercise program.
This may increase the release of endorphins in the brain, promoting a sense of general well-being and increasing appetite. Exercise has been shown to boost mood, reduce anxiety and depression, and improve the quality of life. Additionally, proper posture and body alignment are crucial for optimal swallowing function. Certain exercises can target the core muscles and postural muscles, promoting proper alignment of the head, neck, and trunk.
Administer IV fluids and tube feedings.
It may be necessary for fluid replacement and nutrition if the patient is unable to take anything orally. However, according to a study, compared to the oral nutrition group at discharge, the tube-feeding group tended to have worse general conditions which supported findings from previous studies indicating that clients with higher stroke severity had greater weight loss due to poor nutritional intake after stroke onset (Aoyagi et al., 2021).
Coordinate a multidisciplinary approach to develop a treatment plan that meets individual needs.
The inclusion of dietitians, and speech and occupational therapists can increase the effectiveness of the long-term plans and significantly reduce the risk of silent aspiration. Speech-language pathologists, also known as speech therapists, are considered the experts in assessing and treating dysphagia. Survivors should discuss any new swallowing exercises for stroke clients with their speech therapist as a measure of safety (Denslow, 2023).
Encourage the frequent practice of swallowing exercises as dictated by the speech therapist.
Consistently practicing swallowing exercises can encourage recovery by promoting adaptive changes in the brain. Additionally, practicing swallowing exercises can improve oral-motor coordination and help strengthen the muscles associated with swallowing. The repetitious practice of swallowing exercises promotes faster changes within the brain (Denslow, 2023).
Promote deep breathing exercises.
Breathing exercises are a simple, yet effective, way to address swallowing difficulties. The client may start by taking a slow, intentional deep breath in. The client then should hold their breath for a few seconds, then exhale and repeat. Next, the client should practice inhaling deeply and quickly, followed by exhaling slowly and deliberately. Each of these breathing exercises must be repeated five times (Denslow, 2023).
Educate the caregivers or family members about safety precautions for clients with dysphagia.
Due to their difficulty in swallowing, clients with dysphagia are at a high risk of choking. Therefore, it is essential for family members or caregivers to know when and how to perform the Heimlich maneuver. If a client is unable to cough, talk, or breathe, they are choking. The Heimlich maneuver can help dislodge food blocking the airway through a series of five back blows, followed by five abdominal thrusts (Denslow, 2023).
Prepare the client for neurostimulation as indicated.
With the evidence of neural repair mechanisms and increased cortical activity playing a significant role in the swallowing recovery process following stroke, noninvasive neurostimulation therapies are of particular interest in the treatment of post-stroke dysphagia. Neurostimulation can promote cortical reorganization to accelerate the natural process of stroke recovery and is characterized as peripheral or central stimulation (Jones et al., 2020).
Activity limitations are the difficulties a person might have in executing daily activities. The main activity limitations in clients post-stroke are the inability to walk independently as well as difficulties performing daily life and self-care activities. This can affect their locomotor ability and their community reintegration and could predispose them to a risk of physical inactivity. Since many clients with stroke have low levels of physical activity, which can lead to a recurrence of stroke, physical activity should be considered among post-stroke rehabilitation interventions (Honado et al., 2023).
Assess sleep patterns and note changes in thought processes and behaviors.
Multiple factors can aggravate fatigue, including sleep deprivation, emotional distress, side effects of medication, and progression of the disease process. Characteristics of post-stroke fatigue may include overwhelming tiredness and lack of energy to perform ADLs; the abnormal need for naps, rest, or extended sleep; more easily tired by ADLs than pre-stroke; and unpredictable feelings of fatigue without apparent reason (Lanctot et al., 2019).
Assess the extent to which the client can perform activities of daily living (ADLs).
A stroke can result in profound disruption in the life of an individual. The ability to perform ADLs may require many adaptive changes as well as assistance from family members. After discharge from the hospital, many clients will require continuing help with ADLs, such as moving, bathing, dressing, and toileting. The types and degrees of disability that follow a stroke depend upon which area of the brain is damaged (Pandit et al., 2017).
Assess the level of fatigue and evaluate for other precipitators and causes of fatigue.
Post-stroke fatigue (PSF) has been defined as an “overwhelming feeling of exhaustion or tiredness”, which is unrelated to exertion and does not typically improve with rest. PSF is linked to undesirable stroke outcomes and affects the client’s participation in studies, adherence to medication, and effectiveness of rehabilitation (Aali et al., 2020).
Utilize valid and reliable assessment tools for the identification of fatigue levels.
Fatigue Severity Scale (FSS) was the main outcome measure for PSF in observational studies, while Fatigue Assessment Scale (FAS) was used more frequently than other measures in interventional studies. Both of these scales are valid and reliable, but the main reason that FSS has been used more frequently is probably because it is now seen as a way to compare different studies. Researchers use it because other researchers have used it and is relatively straightforward to complete (Aali et al., 2020).
Assess for signs of post-stroke depression.
Fatigue and depressive symptoms have been shown to co-exist in up to 30% of stroke survivors, which in turn may be associated with cognitive and mobility impairments. The overall prevalence of depression in persons with mild cognitive impairment (MCI) was 32%. Persons with depression may progress more quickly from MCI to dementia. These conditions all have the potential to delay or impede recovery, which may lead to worse long-term outcomes (Lanctot et al., 2019).
Recommend scheduling activities for periods when the client has the most energy. Adjust activities as necessary.
This prevents overexertion and allows for some activity within the client’s ability. ‘Pacing’ or spreading out activities and interspersing them with rests was described as a helpful fatigue management strategy. In a study, many said that if they had an activity at a one-time point in the day, and they managed their fatigue by trying not to do much for other parts of that day. On balance, there was a recognition that activities need to be modified in terms of timing and in terms of the level of participation (Ablewhite et al., 2022).
Encourage the client to do whatever is possible.
This provides a sense of control and a feeling of accomplishment. Self-efficacy is a psychological construct defined as the belief in one’s capabilities to organize and execute the courses of action required to produce given attainments. This construct provides additional energy to people so that the stronger the conviction, the higher the goals, and the stronger the commitment to achieving the goals, despite any adversities (Honado et al., 2023).
Instruct the client, family, or caregiver in energy conservation techniques.
This enhances performance while conserving limited energy and preventing an increase in the level of fatigue. Counseling on energy-conservation strategies that consider optimizing daily function in high-priority activities is recommended, such as daily routines and modified tasks that anticipate energy needs and provide a balance of activity/rest. The client’s day can be structured to include a balance of activity and scheduled periods of rest while anticipating energy requirements for each task and for the completion of high-priority activities. Family members can also be delegated activities that are of low priority (Lanctot et al., 2019).
Plan family and friend visits around the client’s increased sleep time and shorter periods of alertness.
The client may become tired easily and will sleep more. In addition, the client may have periods of unresponsiveness or confusion, or seem to be in a dream state. This may be distressing to some visitors. In a study, most clients also described needing sleep to manage their post-stroke fatigue with some experiencing feeling that they would “crash” if they did not (Ablewhite et al., 2022).
Demonstrate the proper performance of ADLs, ambulation, and position changes.
This protects the client and caregiver from injury during activities. Teach the client to sit rather than stand when possible when doing chores such as washing dishes or ironing. The client should also be educated about using proper body mechanics, posture, and sitting positions and locations (Lanctot et al., 2019).
Encourage nutritional intake and the use of supplements, as appropriate.
A number of stroke survivors described how changes to their diet had improved the way they felt. Some had changed their diet in an attempt to lose weight in order to improve their general health. Others perceived their diet as healthy already and they had made no changes (Ablewhite et al., 2022).
Provide information about the benefits of cognitive behavioral therapy (CBT) and other psychotherapies for the management of PST.
A study including 83 participants with severe fatigue four months post-stroke participated in a 12-week program consisting of group cognitive treatment or group cognitive treatment combined with graded activity training. Cognitive treatment consisted of CBT and compensatory strategy teaching. Clients who received these treatments were significantly more likely to experience clinically relevant improvement in fatigue severity (Lanctot et al., 2019).
Promote good sleep hygiene.
Counsel the client and family members on the establishment of good sleep hygiene behaviors and to avoid sedating drugs and excessive alcohol. Hypersomnia and excessive daytime sleepiness are observed in 27% of clients, whereas insomnia occurs in 57% of clients in the early months after stroke (Hinkle et al., 2017).
Encourage the client to perform relaxation or meditation exercises.
Some clients in a study described how engaging in meditative activities was a beneficial fatigue management strategy that they would recommend. While some used programs, accessed via a website or an app, others spent quiet time recharging their batteries in order to manage their fatigue (Ablewhite et al., 2022).
Promote the use of a fatigue diary.
Keeping a fatigue diary was described as a useful management strategy for coping with PSF. it was thought to be useful to help plan daily and weekly activities in advance and, in particular, it was thought to be valuable in identifying triggers. Caregivers reported using the diary to keep a record of ‘key events’ to enable them to look back, and review activities, and this enabled the identification of fatigue-inducing activities (Ablewhite et al., 2022).
Administer medications as indicated.
Pharmacological agents that have been evaluated in the treatment of PSF include selective serotonin reuptake inhibitors (fluoxetine) and modafinil (Hinkle et al., 2017). Modafinil, a medication originally useful for clients with hypersomnia or narcolepsy to promote wakefulness, relieved PSF in clients with brainstem-diencephalic strokes better than in clients with cortical stroke. A double-blind, placebo-controlled trial conducted on clients with PSF found that fluoxetine was not effective in improving PSF, although it improved depression and other emotional disorders in these clients (Hinkle et al., 2017).
Unilateral spatial neglect (USN) refers to a condition where clients do not react to various environmental stimuli originating from the contralateral side of a brain lesion, in the absence of other sensory or motor deficits. Consequently, activities of daily living can be adversely affected. Cerebral hemorrhage or infarction is often the cause, and approximately 80% of clients with right hemisphere injury from acute stroke show unilateral spatial neglect. Stroke-mediated unilateral spatial neglect may improve or disappear during rehabilitation; however, in most cases, it remains (Osawa & Maeshima, 2021).
Assess the client for signs of unilateral neglect. Signs and symptoms include:
Clients with stroke and unilateral spatial neglect often require careful monitoring for difficulties with daily self-care activities such as eating and dressing, due to neglect of the affected side and the risk of falls and
Progressively increase the client’s ability to cope with unilateral neglect by using assistive devices, feedback, and support during rehabilitation.
Recovery from unilateral neglect generally occurs in the first four weeks after the stroke, with a much more gradual recovery after that. Rehabilitation for USN is broadly classified as a ‘top-down mechanism’ that encourages attention to the neglected side and changes in behavior, and a ‘bottom-up mechanism’ that activates higher-order central nerves due to stimulation from the periphery (Osawa & Maeshima, 2021).
Initiate fall prevention interventions.
Clients with CVA are twice as likely to fall. Ensure that the client’s environment is safe and free from obstacles, therefore, the pathways should be cleared and any tripping hazard must be removed. Place visual cues on the neglected side of the environment to draw attention. These cues can be brightly colored objects, signs, or pictures. See Risk for Falls and Risk for Injury.
Set up the environment so that essential activity is on the unaffected side.
These help in focusing attention and aid in the maintenance of safety. Place the client’s personal items within view and the unaffected side. Position the bed so that the client is approached from the unaffected side. Approaching the client from the unaffected side enhances the client’s awareness and promotes interaction. When a client with USN is discharged, further support is needed including creating an environment such that ADL impairment due to neglect symptoms is reduced to the minimum (Osawa & Maeshima, 2021).
Educate the client to turn the head in the direction of the defective visual field.
This is to compensate for the loss in visual acuity. Encourage the client to actively scan their environment by turning their head and eyes to both sides. Provide verbal or visual cues to remind them to check the neglected side. This technique helps improve attention and reduces the risk of falls.
Teach the client to be aware of the problem and modify behavior and environment.
Awareness of the environment decreases the risk of injury. Training methods may help the client become personally aware of the neglect symptoms and actively pay attention to them. Direct the client or significant other (SO) to position the bed at home so that the client gets out of bed on the unaffected side. Training such as sustained attention training using auditory feedback and visual scanning may help the client recognize these concerns (Osawa & Maeshima, 2021).
Encourage family participation in care and exercise.
Improvement is seen in clients who participated in exercise training with their family members. A study compared a group that performed a family participation type of self-training and a group that underwent training without family participation for approximately three weeks. They reported an improvement in the former group only, with improvements in the transfer/mobility capability, which are indices of ADLs (Osawa & Maeshima, 2021).
Teach the client how to scan regularly to check body parts’ position and to periodically turn their head from side to side when ambulating or doing ADLs.
Reinforcement of this technique helps increase client safety. Saccadic compensation training aims at improving the quick and safe visual overview of a visual scene. It can be assumed that visual scanning training almost always includes attentive elements (Platz, 2021).
Speak in a calm, comforting, quiet voice, using short sentences. Maintain eye contact.
The client may have a limited attention span or problems with comprehension. These measures can help clients attend to communication. Clients with USN often have difficulty attending to stimuli on their neglected side. Speaking in a calm, comforting voice can help them focus and direct their attention toward the speaker, increasing the chances of them perceiving and processing the information being communicated.
Ascertain the client’s perceptions. Reorient the client frequently to the environment, staff, and procedures.
This assists the client to identify inconsistencies in the reception and integration of stimuli and may reduce perceptual distortion of reality. Reorientation helps the client become more aware of their surroundings, including the neglected side. By reminding them of their location and the environment, promotes attention and can improve their ability to perceive and attend to stimuli on the neglected side.
Approach the client from the visually intact side. Leave the light on; position objects to take advantage of intact visual fields. Patch affected eye if indicated.
This helps the client to recognize the presence of persons or objects and may help with depth perception problems. This also prevents clients from being startled. Patching the eye may decrease sensory confusion of double vision. A half-opaque eye patch is a widely used method for improving visuospatial attention and focus on the neglected side by artificially masking the view of the normal side (AeYang, 2019).
Stimulate the sense of touch. Give the client objects to touch, and hold. Have the client practice touching walls and boundaries.
This aids in retraining sensory pathways to integrate the reception and interpretation of stimuli and helps the client orient self spatially and strengthens the use of the affected side. Provide tactile cues or gentle touches on the neglected side of the body to draw attention to that side. The client may also explore different textures using their neglected hand or fingertips by using fabrics, sandpaper, or different textured surfaces. The nurse may guide them to touch and feel these textures.
Encourage the client to watch their feet when appropriate and consciously position body parts.
The use of visual and tactile stimuli assists in the reintegration of the affected side and allows the client to experience forgotten sensations of normal movement patterns. Sustained attention training increases a client’s arousal through the presence of external alerting stimuli produced and results in significant improvements in cancellation tests (Physiopedia, 2023).
Provide information about mirror therapy.
Mirror therapy can be carried out by having the client place both of their arms on a table with a mirror placed between their arms. They are then required to look in the mirror while moving both arms. The reflecting side of the mirror faces the non-affected arm. Mirror therapy has been shown to have a significant effect on spatial neglect (Physiopedia, 2023).
Prepare the client for transcutaneous electrical nerve stimulation (TENS).
TENS of the posterior aspect of the sternocleidomastoid muscle can be used to improve postural control in clients with neglect. TENS treatment combined with visual scanning training leads to significant improvements in neglect tests lasting less than a week and significant improvements in reading and writing tasks lasting more than a week (Physiopedia, 2023).
Sarcopenia is the loss of skeletal muscle mass and strength with aging and has become a worldwide social issue with an increased risk of adverse outcomes, including falls, fractures, longer hospitalization duration, physical disability, and mortality. The loss of skeletal muscle mass and strength in clients with stroke is called stroke-related sarcopenia (SRS). SRS decreases the treatment effect and affects the quality of life of the clients (Yao et al., 2022).
Assess for subluxation of the shoulder, such as severe pain and swelling, tingling sensation, inability to move the joint, and altered appearance of bony prominences.
Shoulder subluxation happens when the muscles around the shoulder become weak, resulting in the separation of the shoulder joint. The nurse may use the fingerbreadth palpation method when assessing for shoulder subluxation. The client should sit in a chair or wheelchair with both feet flat on the ground or footrest. The nurse first assesses the unaffected side to palpate the gap between the acromion and the humerus head, and repeat the same on the affected shoulder. Shoulders should be positioned in neutral rotation, with the arm hanging by the side (thumb pointing forward) close to the body with no abduction (Physiopedia, 2022).
Assess for the presence of unilateral spatial neglect.
Unilateral neglect can often be seen in a client’s behavior even before a conclusive diagnosis, as there will frequently be a distinct lack of awareness displayed by the client toward the affected side. There are several tests that specifically evaluate the spatial or visual presentation of unilateral neglect. Examples are the line bisection, the single letter cancellation, the clock drawing neglect, and the behavior inattention tests (Physiopedia, 2023).
Instruct the client to inspect their extremities first, then check the position before ambulating.
These are safety precautions to avoid falling. For instance, alert the client to make a conscious effort to raise and extend the foot when ambulating. This can also be done through feedback training. Feedback training can be achieved through verbal, video, and visual feedback. Simply pointing out a client’s neglect behavior (verbal feedback) or showing them a video of their performance can lead to an increase in self-awareness and a decrease in neglect symptoms (Physiopedia, 2023).
Provide a pillow or lapboard to be used as support in positioning the client in the correct alignment.
These interventions aid in maintaining the anatomic position. Lap trays, pillows, and foam support help to keep the arm and shoulder supported in the correct position. Good positioning will help reduce the strain on the ligaments and prevent a frozen shoulder from occurring (Physiopedia, 2022).
Instruct the client with balance problems to adjust by leaning toward the stronger side to ensure correct upright posture.
Stroke clients tend to lean heavily on their weak side. It is reported that about 83% of stroke survivors suffer from balance impairment. Balance impairment is characterized by short supporting time and differences between two sides of the body and slow walking speed, which may increase the risk of falls (Li et al., 2019).
Encourage the use of an arm sling.
The sling supports and protects the arm and shoulder while the client is standing or ambulating. Studies have shown the effectiveness of slings to prevent subluxation, but no investigation assessed the efficacy of slings in relation to the duration of their use. Supports from slings have various purposes: realigning scapular symmetry, supporting the forearm in a flexed arm position, improving anatomic alignment with auxiliary support, or supporting the shoulder with a cuff (Physiopedia, 2022).
Avoid pulling the affected arm. Place a hand behind the scapula when moving the upper extremity instead of pulling from the arm. Utilize a lift sheet during bed repositioning. When the client is sitting, provide the arm with a firm support surface
These are interventions that help prevent subluxation and deformity. When in bed, the shoulder should be placed a bit forward to counteract shoulder rotation. The affected arm should be placed in external rotation as the client is lying on the affected side. Factors that contribute to subluxation include improper positioning, lack of support in the upright position, pulling on the hemiplegic arm when the client is transferred, and severe loss of motor function and apparent absence of supraspinatus muscle contraction (Physiopedia, 2022).
Provide instructions on transfer techniques utilizing the stronger extremity to move the weaker extremity.
For example, to move the affected leg in bed or when changing from a lying to a sitting position, slide the unaffected foot under the
affected ankle to lift, support, and bring the affected leg along in the desired movement. Use proper body mechanics to promote safety for all involved during a transfer and/or repositioning task. Never pull on the affected arm or grab under the shoulder or armpit. This can cause shoulder pain, injury, and long-lasting complications (Canadian Stroke Best Practices, 2020).
Instruct the client to use proper footwear. Avoid the use of slippers.
Well-fitting footwear helps improve balance. Using slippers may put the client at risk of falls. Inappropriate footwear refers to both particular types of footwear with unsafe features, as described in the Footwear Assessment Form (FAF), and also footwear of an incorrect size. Wearing inappropriate footwear has been associated with falls. A shoe’s material and tread design can affect the coefficient of friction on the walking surface, which may influence the risk of slipping (O’ Rourke et al., 2020).
Provide a light joint range of motion exercises and proper arm positioning to avoid shoulder-hand syndrome. Encourage repeated shoulder movement and regular fist clenching and unclenching.
Shoulder-hand syndrome is a neurovascular condition characterized by pain, edema, and skin and muscle atrophy due to impairment of the circulatory pumping action of the upper extremity. In the early rehabilitation phase, passive range of motion exercises has been shown to effectively prevent shoulder subluxation among stroke clients. Range of motion exercises includes flexion-extension, abduction-adduction, and external-internal rotation (Physiopedia, 2022).
Instruct and apply the following transfer principles:
These are methods to follow when moving clients with impaired physical mobility. These transfer principles emphasize using the stronger or unaffected side to help support clients for safe transfers to reduce the risk of falling. The client, family, and caregiver should also receive skills training to enable them to safely transfer and mobilize the client. Using correct and safe techniques for transfers and repositioning, mobility methods, and appropriate equipment to help a person transfer and change position will increase their safety, confidence, and independence (Canadian Stroke Best Practices, 2020).
If the client needs assistance from a health care staff, refrain the client from pulling on or putting hands around the assistant’s neck as a means to support.
Staff members should utilize their knees and feet to brace the feet and the knees of weak clients. The nurse should position themselves close to the client to avoid overreaching. The shoulders should be in a neutral position and the abdominal muscles should be tightened to engage the core. Then the nurse must stand with a sturdy and wide base of support so they will be in better control and can stay balanced (Canadian Stroke Best Practices, 2020).
Secure referral to physical therapy and occupational therapy if needed. Reinforce special mobilization techniques such as proprioceptive neuromuscular rehabilitation, neurodevelopmental treatment, motor relearning program, and constraint-induced movement therapy per the client’s individualized rehabilitation program.
These techniques may vary from the general principles mentioned. For example, Bobath focuses on using the affected side in mobility training so that clients try to bear weight on their affected side and move toward their affected side to relearn normal movement patterns and positions. Movement therapy involves restraining the functioning arm to induce “rewiring of the brain,” thereby improving functional movement. Constraint-induced movement therapy, action observation training, and mirror therapy have been recently studied as therapies for upper-extremity motor function. These interventions are used to increase the use of paralyzed limbs to overcome disuse syndromes (Choi et al., 2019).
Provide instructions about mirror therapy.
Mirror therapy for stroke clients was reported to be effective in upper-extremity motor function and daily life activity performance. However, conventional mirror therapy methods require high concentration and can become tedious, making active participation difficult. Results of a study suggest that mirror therapy with a gesture recognition device has a positive effect on upper-extremity motor function and quality of life of clients with chronic stroke (Choi et al., 2019).
Stroke remains a leading cause of disability among adults in the United States and globally. Of the estimated 800,000 strokes that occur in the US per year, the majority of stroke survivors develop long-term functional deficits. Post-stroke motor recovery is a complex, dynamic, and multifactorial process in which an interplay among genetic, pathophysiologic, sociodemographic, and therapeutic factors determines the overall recovery trajectory (Alawieh et al., 2018).
Assess the type and degree of hemisphere injury the client exhibits.
This describes right and left hemisphere injuries. If the stroke occurs in the left side of the brain, the right side of the body will be affected, producing paralysis if the right side of the body, speech/language problems, slow, cautious behavioral style, and memory loss. If the stroke occurs in the right side of the brain, the left side of the body will be affected, producing paralysis on the left side of the body, vision problems, quick, inquisitive behavioral style, and memory loss (American Stroke Association, 2023).
Evaluate for visual deficits. Note the loss of visual field, changes in in-depth perception (horizontal and/or vertical planes), and the presence of diplopia (double vision).
The presence of visual disorders can negatively affect a client’s ability to perceive the environment and relearn motor skills and increases the risk of accident and injury. Clients with neglect or spatial inattention do not respond to, and are not aware of, things on their stroke-affected side. This problem is not related to vision, but results from damage to parts of the brain that perceive and interpret vision (American Stroke Association, 2023).
Assess sensory awareness: dull from sharp, hot from cold, position of body parts, and joint sense.
Diminished sensory awareness and impairment of kinesthetic sense negatively affect balance and positioning and appropriateness of movement, which interferes with ambulation, increasing the risk of trauma. Many stroke survivors experience somatosensory impairment. This impacts adversely on the ability to detect, discriminate, and recognize sensations from the body because somatosensory function includes tactile sensation, vibration, pressure, proprioception, temperature, and pain (Aries et al., 2021).
Note inattention to body parts, segments of the environment, and lack of recognition of familiar objects/persons.
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. Spatial inattention, often called neglect, can result in not paying attention to the side of the body affected by stroke. In some cases, it can seem like there’s no left side of the body because the brain is not processing information from that side very efficiently (American Stroke Association, 2023).
Encourage clients with non-dominant (right) hemisphere injury to slow down and check each step or task as it is completed.
Clients with non-dominant (right) hemisphere injury may also have decreased pain sensation and sense of visual field deficit but are typically unconcerned or unaware of or deny deficits or lost abilities. They tend to be impulsive and too quick with movements. Typically, they have impaired judgment about what they can and cannot do and often overestimate their abilities. These individuals are at risk for burns, bruises, cuts, and falls and may need to be restrained from attempting unsafe activities. They also are more likely to have unilateral neglect than individuals with dominant (left) hemisphere injury.
Remind clients who have a dominant (left) hemisphere injury to scan their environment.
These clients may lack or have decreased pain sensation and position sense and have visual field deficits on the right side of the body. They may need reminders to scan their environment but usually do not exhibit unilateral neglect. Visual exploration training can be conducted by training both smooth pursuit and saccadic eye movements. Visual scanning training is the most commonly used method among clinicians and several studies have shown its effectiveness in reducing unilateral neglect (Choi et al., 2019).
Encourage making a conscious effort to scan the rest of the environment by turning the head from side to side.
The client may have visual field deficits in which they can physically see only a portion (usually left or right side) of the normal visual field (homonymous hemianopsia). Training methods using the top-down mechanism include sustained attention training using auditory feedback and visual scanning. With these methods, the client needs to be personally aware of the neglect symptoms and actively pay attention to them (Osawa & Maeshima, 2021).
Give short, simple messages or questions and step-by-step directions. Keep the conversation on a concrete level (e.g., say “water,” not “fluid”; “leg,” not “limb”).
These individuals may have poor abstract thinking skills. They tend to be slow, cautious, and disorganized when approaching an unfamiliar problem and benefit from frequent, accurate, and immediate feedback on performance. They may respond well to nonverbal encouragement, such as a pat on the back. Vascular dementia, which is commonly associated with left-hemisphere stroke, impacts reasoning, planning, judgment, memory, and other thought processes (American Stroke Association, 2023).
Have clients with apraxia return your demonstration of the task or see if they are able to be talked through a task or may be able to talk themselves through a task step-by-step.
To optimize client knowledge and health outcomes across the spectrum of health literacy, nurses must use evidence-based methods, such as teach-back. A systematic review identified improved healthcare outcomes in disease-specific knowledge, adherence, and self-efficacy. A meta-analysis evaluating the effectiveness of discharge education revealed using the teach-back method was effective in reducing unplanned 30-day readmissions (Camicia et al., 2021).
Keep the client’s environment simple to reduce sensory overload and enable concentration on visual cues. Remove distracting stimuli.
The client may have an impaired ability to recognize objects using the senses of hearing, vibration, or touch. These clients rely more on visual cues. When a client with unilateral neglect is discharged, further support is needed including creating an environment such that ADL impairment due to neglect symptoms is reduced to the minimum, giving the family an adequate explanation of the symptoms prior to discharge, and maximizing the use of social systems (Osawa & Maeshima, 2021).
Assist clients with eating. Monitor the environment for safety hazards, and remove hazardous objects such as scissors from the bedside.
The client may have difficulty recognizing and associating familiar objects. Clients may not know the purpose of silverware. These clients may not recognize hazardous objects because they do not know the purpose of the object or may not recognize subtle distinctions between objects (e.g., the difference between a fork and a spoon may become too subtle to detect). Cognitive deficits are changes in thinking, like difficulty solving problems. This category also includes dementia and memory problems, as well as communication challenges (American Stroke Association, 2023).
Teach the client to concentrate on body parts, for example, by watching the swaying of hands or movement of the feet while walking. Using a mirror can also help them adjust.
The client may experience a misconception of their own body and body parts. These clients may not perceive their foot or arm as part of their body. Mirror therapy for stroke clients was reported to be effective in upper-extremity motor function and daily life activity performance. The paralyzed body parts are covered with a mirror. The mirror is placed in the center of the body, and the movement of the paralyzed body is viewed through the mirror. The client has a visual illusion that the paralyzed side is normally moving (Choi et al., 2019).
Provide these clients with a restraint or wheelchair belt for support.
The client may experience an inability to orient themselves in space. They may not know if they are standing, sitting, or leaning. Even if the client is sitting on a bed or in a wheelchair, they may face one direction for a prolonged period, or fail to notice another person in the room. Stroke clients with unilateral neglect often require careful monitoring for difficulties with daily self-care activities such as eating and dressing, due to neglect of the affected side and the risk of falls and fractures associated with transfers and walking (Osawa & Maeshima, 2021).
Provide a structured, consistent environment. Mark the outer aspects of the client’s shoes or tag inside the sleeve of a sweater or pair of pants with “L” and “R.”
The client may have a visual-spatial misconception. The client may have trouble judging distance, size, position, rate of movement, form, and how parts relate to the whole. For example, the client may underestimate distances and bump into doors or confuse the inside and outside of an object, such as an article of clothing. These clients may lose their place when reading or adding up numbers and therefore never complete the task.
Direct the client’s attention to a particular sound (e.g., playing different musical instruments and associating its sound with its name.)
The client may have an impaired ability to recognize, associate, or interpret sounds. After a stroke, the client may be highly sensitive to sound. It is a common side effect called auditory overload. The brain cannot keep up with the amount of sensory information it receives (American Stroke Association, 2023).
Protect from temperature extremes; assess the environment for hazards. Recommend testing warm water with an unaffected hand.
This promotes client safety, reducing the risk of injury. Sensory issues like these often occur after a stroke has damaged a part of the brain that helps regulate sensation. Sensory issues after a stroke can take many different forms. Some client experience numbness on the affected side. In some cases, stroke survivors have trouble distinguishing between sensations of hot and cold or light vs. deep pressure (Cairer, 2023).
Assist the client during sensory retraining exercises.
Through sensory reeducation, survivors can retrain the brain to process sensory signals again, promoting the return of sensation after stroke. This occurs through intentional rehabilitation that includes the consistent practice of sensory retraining exercises. These exercises encourage neuroplasticity (the brain’s ability to heal and create new neural pathways) by providing stimulation to the brain to help promote sensory processing (Cairer, 2023).
Educate the client and caregivers about how to continue sensory retraining at home.
The client may perform sensory training exercises at home at least ten times for about 10 to 15 minutes a day. The client may perform tabletop touch therapy which involves a variety of objects with different textures that the client may distinguish the difference between them. Temperature differentiation involves using hot and cold materials to help rewire the neural pathways for temperature distinction (Cairer, 2023).
Getting the right information about stroke was often of great importance to clients and caregivers and aided the processes of reassurance and adjustment. The desire for information as a resource for empowerment and psychological adjustment has been found in many different conditions and is supported by a recent systematic review which demonstrated that information provision post-stroke reduced client depression. Thus, improving information provision could play a role in reducing the need for more formal psychological support (Harrison et al., 2017).
Assess the type and degree of sensory-perceptual involvement.
This will affect the choice of teaching methods and the content complexity of instruction. The pattern of cognitive deficits in vascular cognitive impairment may encompass any cognitive domain. The most common areas are attention, processing speed, and frontal-executive functions, which include functions such as planning, decision-making, judgment, error correction, impairments in the ability to maintain a task set, inhibiting a response, or shift from one task to another, and deficits in the ability to hold and manipulate information (Lanctot et al., 2019).
Identify signs and symptoms requiring further follow-up: changes or decline in visual, motor, and sensory functions; alteration in mentation or behavioral responses; severe headache.
Prompt evaluation and intervention reduce the risk of complications and further loss of function. Clients with stroke and transient ischemic attack should be considered for screening for vascular cognitive impairment. This may occur prior to discharge from acute care if concerns with cognition are identified; during inpatient rehabilitation, and during post-stroke follow-up in outpatient and community settings (Lanctot et al., 2019).
Identify individual risk factors (e.g., hypertension, cardiac dysrhythmias, obesity, smoking, heavy alcohol use, atherosclerosis, poor control of diabetes, use of oral contraceptives) and discuss necessary lifestyle changes.
This promotes general well-being and may reduce the risk of recurrence. Note: Obesity in women has been found to have a high correlation with ischemic stroke. According to the Global Burden of Disease (GBD) 2013 study, potentially modifiable risk factors cause more than 90% of the stroke burden, and more than 75% of this burden could be reduced by controlling metabolic and behavioral risk factors (Pandian et al., 2018).
Assess the client’s and family members’ health literacy.
Effective client and family education begins with an understanding of an individual’s health literacy, that is, their capacity to obtain, process, and understand health information, and provide information in ways that are meaningful, understandable, timely, and with the appropriate amount of content based on the learner’s readiness. Validated tools to assess health literacy such as Rapid Assessment of Adult Health Literacy in Medicine, The Test of Functional Health Literacy in Adults, and The Newest Vital Sign are available via the Health Literacy Toolshed (Camicia et al., 2021).
Include significant others (SO) and the family in discussions and teaching.
These people will be providing support and care, thus having a significant impact on the client’s quality of life and home health care. The discharge transition from the inpatient setting to the home and community is one of the most vulnerable and significant events in the continuum of care for stroke survivors and their families (Camicia et al., 2021).
Discuss specific pathology and individual potentials.
This aids in establishing realistic expectations and promotes an understanding of the current situation and needs. The top educational needs identified by stroke survivors in a review of 21 studies were information and education on the stroke signs, symptoms, and prevention, treatment modalities and medications, stroke recovery and return to work, causes of stroke, and providing physical care to the stroke survivor, including transfers, lifting, and personal care (Camicia et al., 2021).
Review current restrictions and discuss the potential resumption of activities (including sexual relations).
This promotes understanding, provides hope for the future, and creates the expectation of the resumption of a more “normal” life. Another review of 66 studies found that the most critical stroke survivors’ educational needs were related to functional needs; activity and participation; and environmental concerns (Camicia et al., 2021).
Reinforce the current therapeutic regimen, including using medications to control hypertension, hypercholesterolemia, and diabetes, as indicated; aspirin or similar-acting drugs, for example, ticlopidine, warfarin sodium. Identify ways of continuing the program after discharge.
Recommended activities, limitations, and medication and therapy needs are established based on a coordinated interdisciplinary approach. Follow-through is essential to the progression of recovery and prevention of complications. Long-term anticoagulation may be beneficial for clients older than 45 who are prone to clot formation; however, using these drugs is not practical for CVA resulting from vascular aneurysms or vessel rupture. Effective and timely communication within and across settings, professions, and with the client and family must occur during every transition (Camicia et al., 2021).
Provide written instructions and schedules for activity, medication, and essential facts.
This provides visual reinforcement and reference sources after discharge. Written prescriptions for exercise and medications for smoking cessation increase the likelihood of success with these interventions (Jauch & Lutsep, 2022). Clients and caregivers preferred face-to-face delivery of information except for information about services and benefits where the preferred mode was written (Camicia et al., 2021).
Encourage the client to refer to written communications or notes instead of depending on memory.
This provides aid to support memory and promotes improvement in cognitive skills. The AHA/ASA has a series of downloadable educational materials, Let’s Talk about Stroke that can be used to provide standardized education. As with many of the collaborative models of stroke care that have been developed with stroke centers, emergency medical services, and mobile stroke units, providers across the stroke care continuum can work together to identify standardized educational information that can consistently be provided within and across care settings (Camicia et al., 2021).
Discuss plans for meeting self-care needs.
Varying levels of assistance may need to be planned for based on the individual situations. In recent years, self-management has become part of the stroke care pathway, since it could support individuals facing the long-term consequences of stroke, and thus it could facilitate interventions related to transitional care (Fugazzaro et al., 2020).
Suggest clients reduce environmental stimuli, especially during cognitive activities.
Multiple stimuli may aggravate confusion, overwhelm the client, and impair mental abilities. Cognitive rehabilitation interventions associated with stroke focus on common deficits of attention, memory, or executive function. Enriched environments improved measures of working memory but not attention (Lanctot et al., 2019).
Recommend clients seek assistance in the problem-solving process and validate decisions, as indicated.
Some clients (especially those with the right CVA) may display impaired judgment and impulsive behavior, compromising their ability to make sound decisions. Executive function deficits may be treated with metacognitive strategy training and/or formal problem-solving strategies, under the supervision of a trained therapist. Internal strategy training may also be considered and includes strategies to improve goal management, problem-solving, time management, and metacognitive reasoning (Lanctot et al., 2019).
Review the importance of a balanced diet, low in cholesterol and sodium if indicated. Discuss the role of vitamins and other supplements.
This improves general health and well-being and provides energy for life activities. Adherence to dietary patterns rather than consumption of particular foods or nutrients has been increasingly associated with cardiovascular health, particularly with stroke risk. The use of seasonal, healthy, regional foods and taxes and subsidies on specific foods could be a means to decrease cardiometabolic diseases and stroke at a population level (Pandian et al., 2018).
Reinforce the importance of follow-up care by rehabilitation teams: physical and occupational therapists, vocational therapists, speech therapists, and dieticians.
Consistent work may eventually lead to minimized or overcoming residual deficits. Studies of advanced practice nurse-led transitional care models have been shown to reduce hospital readmissions. The interventions included follow-up phone calls postdischarge, home and clinic visits with linkages to primary care, identification of client health care goals, education on signs and symptoms and strategies to reduce disease exacerbation, reconciliation of medications, and handoff treatment plan to the primary care provider (Camicia et al., 2021).
Refer to a home care supervisor or a visiting nurse.
The home environment may require evaluation and modifications to meet individual needs. Ensuring a seamless transition requires clear and frequent communication between the interprofessional team and the case manager or a transition specialist about the transition care plan. The Association of Rehabilitation Nurses Competency Model for Professional Rehabilitation Nursing includes role descriptors for nurses practicing at intermediate and advanced proficiency levels such as identifying potential barriers to a safe transition home, coordinating and modifying the plan as additional data are collected, and implementing and evaluating the plan (Camicia et al., 2021).
Provide accessible and reliable community sources.
A key component of providing smooth transitions to home after inpatient stroke care is connecting the clients and their caregivers to appropriate and accessible community resources. The most commonly needed resources include outpatient therapies, home-delivered meals, transportation, financial assistance, assistance with household tasks, community-based exercise programs, and support groups (Camicia et al., 2021).
Implement evidence-based methods of health education.
To optimize client knowledge and health outcomes across the spectrum of health literacy, nurses must use evidence-based methods, such as teach-back and health coaching. Health coaching which involves partnering with clients and caregivers to provide support and establish goals for recovery and self-management activities of daily living has been shown to improve post-discharge outcomes. Coaching focuses on developing problem-solving skills, increasing capacity for managing chronic health conditions, and improving client and caregiver confidence (Camicia et al., 2021).
Address the needs of family caregivers.
Nurses should also assess the family caregivers for their commitment and capacity to provide necessary care, especially for the transition home. Discharge care plans should not only be based on an assessment of the client’s or care recipient’s needs but also on the needs and gaps in the preparedness of the family caregiver. Caregivers report feeling overwhelmed, having difficulty managing the transition home, and indicating their needs for discharge preparation are often not met (Camicia et al., 2021).
Strengthen the healthcare staff’s knowledge about stroke and post-stroke care.
Assisting stroke survivors and caregivers with the transition across diverse care settings and to the community requires unique nursing knowledge and skills. The Association of Rehabilitation Nurses Competency Model for Professional Rehabilitation Nursing includes beginner to advanced-level competencies that can be applied to nursing roles across the stroke care continuum. Nurses must be able to identify current stroke guidelines, use resources for nurses, and have knowledge of and share resources with clients and family caregivers (Camicia et al., 2021).
Thrombolytics: Tissue plasminogen activator (tPA), recombinant tPA (rt-PA)
These are given concurrently with an anticoagulant to treat ischemic stroke. tPA converts plasminogen to plasmin, dissolving the blood clot that is blocking blood flow to the brain. Fibrinolytic therapy is administered 3 to 4.5 hours after symptom onset was found to improve neurologic outcomes in the European Cooperative Acute Stroke Study III (ECASS III), suggesting a wider time window for fibrinolysis in carefully selected clients (Jauch & Lutsep, 2022). It is given intravenously (or intra-arterial delivery) as soon as ischemic stroke is confirmed. Monitor for signs of bleeding. Thrombolytics are contraindicated in clients with hemorrhagic stroke.
Anticoagulants: warfarin sodium, low-molecular-weight heparin
These are administered to prevent further extension of the clot and formation of new clots and improve cerebral blood flow. They do not dissolve an existing clot. Clients with embolic stroke who have another indication for anticoagulation may be placed on anticoagulation therapy nonemergently, with the goal of preventing further embolic disease. However, the potential benefits of that intervention must be weighed against the risk of hemorrhagic transformation (Jauch & Lutsep, 2022). Anticoagulants are never administered to clients with hemorrhagic stroke.
Antiplatelet agents: aspirin, dipyridamole, ticlopidine
Daily low-dose administration of aspirin interferes with platelet aggregation. It can help decrease the incidence of cerebral infarction in clients who have experienced TIAs from a stroke of embolic or thrombotic in origin. AHA/ASA guidelines recommend giving aspirin, 325 mg orally, within 24 to 48 hours of ischemic stroke onset (Jauch & Lutsep, 2022). These medications are contraindicated in hypertensive clients because of the increased risk of hemorrhage.
Antifibrinolytics: aminocaproic acid
This is used with caution in hemorrhagic disorder to prevent lysis of formed clots and subsequent rebleeding. Fibrinolytics restore cerebral blood flow in some clients with acute ischemic stroke and may lead to improvement or resolution of neurologic deficits. Unfortunately, fibrinolytics may also cause symptomatic intracranial hemorrhage (Jauch & Lutsep, 2022).
Antihypertensives: ACE inhibitors, diuretics
These are used for clients undergoing fibrinolytic therapy; blood pressure control is essential to decrease the risk of bleeding. Thresholds for antihypertensive treatment in acute ischemic stroke clients who are not fibrinolysis candidates, according to the 2013 ASA guidelines, are systolic blood pressure higher than 200 mm Hg or diastolic blood pressure above 120 mm Hg. A reasonable goal is to lower blood pressure by 15% during the first 24 hours after the onset of the stroke. (Jauch & Lutsep, 2022) Antihypertensives are also used for secondary stroke prevention.
Peripheral vasodilators: nitroprusside sodium
Transient hypertension often occurs during an acute stroke and usually resolves without therapeutic intervention. It is used to improve collateral circulation or decrease vasospasm. Vasodilators lower blood pressure through direct vasodilation and relaxation of the vascular smooth muscle (Jauch & Lutsep, 2022).
Neuroprotective agents: excitatory amino acid inhibitors and gangliosides.
The rationale for the use of neuroprotective agents is that reducing the release of excitatory neurotransmitters by neurons in the ischemic penumbra may enhance the survival of these neurons. However, no single neuroprotective agent in ischemic stroke has as yet been supported by randomized, placebo-controlled human studies (Jauch & Lutsep, 2022).
Anticonvulsants: phenytoin and phenobarbital; benzodiazepines: diazepam, lorazepam
Generally, agents used for treating recurrent convulsive seizures are also used in clients with seizures after a stroke. Benzodiazepines, typically diazepam and lorazepam, are the first-line drugs for ongoing seizures. Diazepam is useful in controlling active seizures and should be augmented by longer-acting anticonvulsants such as phenytoin or phenobarbital (Jauch & Lutsep, 2022).
Stool softeners.
This prevents straining during bowel movement and the corresponding increase of ICP. Constipation frequently occurs after a stroke (Li et al., 2017). Clients who experienced a stroke typically reduce their physical mobility, fluid intake, and fiber intake because they may have difficulty swallowing. Furthermore, dependence on others to use the toilet may lead to constipation. Finally, the use of medications that can affect bowel function, dehydrating agents, for example, may prevent the gut from absorbing water (Li et al., 2017).
Administer insulin therapy as indicated.
Blood sugar control should be tightly maintained with insulin therapy, with the goal of establishing normoglycemia (90 to 140 mg/dL). Additionally, close monitoring of blood sugar levels should continue throughout hospitalization to avoid hypoglycemia (Jauch & Lutsep, 2022).
Monitor laboratory studies as indicated: prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level.
This provides information about drug effectiveness and therapeutic level. Coagulation studies may reveal a coagulopathy and are useful when fibrinolytic or anticoagulants are to be used. In clients who are not taking anticoagulants or antithrombotics and in whom there is no suspicion of coagulation abnormality, administration of rt-PA should not be delayed while awaiting laboratory results (Jauch & Lutsep, 2022).
Monitor computed tomography scan.
A CT scan is the initial diagnostic test performed for clients with a stroke that is executed immediately once the client presents to the emergency department. CT scan is used to determine if the event is ischemic or hemorrhagic as the type of stroke will guide therapy. A computed tomography angiography (CTA) may also be performed to detect intracranial occlusions and the extent of occlusion in the arterial tree (Menon & Demchuk, 2011). The expedient acquisition is of utmost importance in acute stroke imaging because of the narrow window of time available for definitive ischemic stroke treatment with pharmacologic agents and mechanical devices (Jauch & Lutsep, 2022).
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
Other nursing care plans related to neurological disorders:
Matt Vera, a registered nurse since 2009, leverages his experiences as a former student struggling with complex nursing topics to help aspiring nurses as a full-time writer and editor for Nurseslabs, simplifying the learning process, breaking down complicated subjects, and finding innovative ways to assist students in reaching their full potential as future healthcare providers.
there is a lot of good information but I don’t know how to cite the website and the author in the APA format Reply
