eNursing Care Plan 57-1

Patient with Stroke

Nursing Diagnosis*
Decreased Intracranial Adaptive Capacity
Etiology: decreased cerebral perfusion pressure of ≤ 50-60 mm Hg and sustained increase
in ICP due to thrombus, embolus, or hemorrhage
Supporting data: Baseline ICP ≥15 mm Hg, elevated systolic blood pressure, bradycardia,
widened pulse pressure, increasing NIH Stroke Scale score

Patient Goal
Has signs of stable or improved cerebral perfusion

Outcomes (NOC) Interventions (NIC) and Rationales

Tissue Perfusion: Cerebral
 Intracranial pressure _____
 Systolic blood pressure _____
 Diastolic blood pressure _____
Measurement Scale
1 = Severe deviation from normal
range
2 = Substantial deviation from
normal range
3 = Moderate deviation from normal
range
4 = Mild deviation from normal
range
5 = No deviation from normal range
 Restlessness _____
 Decreased level of
consciousness _____
 Impaired cognition _____
 Impaired neurologic reflexes
_____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Cerebral Perfusion Promotion
 Consult with HCP to determine hemodynamic
parameters, and maintain hemodynamic
parameters within this range to ensure adequate
cerebral oxygenation.
 Monitor neurologic status to detect changes
indicative of worsening or improving condition.
 Calculate and monitor cerebral perfusion pressure
(CPP) to detect change in condition.
 Monitor respiratory status (e.g., rate, rhythm, and
depth of respirations; PaO2, PaCO2, pH, and
bicarbonate levels) because high PaCO2 and a
high hydrogen ion concentration (acidosis) are
potent vasodilators that increase cerebral blood
flow.
 Monitor patient’s ICP and neurologic responses to
care activities because changes in positioning and
movement can increase ICP.
 Monitor determinants of tissue oxygen delivery
(e.g., PaCO2, SaO2, hemoglobin levels, and cardiac
output) to ensure adequate cerebral oxygenation.
 Administer and titrate vasoactive drugs, as
ordered, to maintain hemodynamic parameters.
 Avoid neck flexion or extreme hip or knee flexion
to avoid obstruction of arterial and venous blood
flow.

*Nursing diagnoses listed in order of priority.

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eNursing Care Plan 57-2

Nursing Diagnosis
Risk for Aspiration
Risk factors: Decreased level of consciousness, decreased or absent gag and swallowing
reflexes

Patient Goals
1. Has ability to swallow oral foods without aspiration
2. Maintains a clear airway

Outcomes (NOC) Interventions (NIC) and Rationales

Respiratory Status: Airway Aspiration Precautions
Patency  Monitor level of consciousness, cough reflex, gag
 Depth of inspiration _____ reflex, and swallowing ability to determine
 Ability to clear secretions patient’s ability to swallow food without aspiration.
_____  Avoid liquids or use thickening agent to facilitate
swallowing.
Measurement Scale  Feed in small amounts to reduce risk for aspiration.
1 = Severe deviation from normal  Offer foods or liquids that can be formed into a
range bolus before swallowing.
2 = Substantial deviation from
normal range
3 = Moderate deviation from normal Airway Management
range  Auscultate breath sounds, noting areas of decreased
4 = Mild deviation from normal or absent ventilation and presence of adventitious
range sounds to identify airway obstruction and
5 = No deviation from normal range accumulation of secretions.
 Remove secretions by encouraging coughing or by
 Adventitious breath sounds suctioning to clear airway.
_____  Encourage slow, deep breathing; turning; and
 Accumulation of sputum _____ coughing to increase airway clearance without
increasing ICP.
Measurement Scale  Assist with incentive spirometer to open collapsed
1 = Severe alveoli, promote deep breathing, and prevent
2 = Substantial atelectasis.
3 = Moderate
4 = Mild
5 = None

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eNursing Care Plan 57-3

Nursing Diagnosis
Impaired Physical Mobility
Etiology: Neuromuscular and cognitive impairment, decreased muscle strength and
control
Supporting data: Limited ability to perform gross and fine motor skill activities, limited
range of motion, difficulty turning

Patient Goals
1. Has increased muscle strength and ability to move
2. Uses adaptive equipment to increase mobility

Outcomes (NOC) Interventions (NIC) and Rationales

Mobility
 Balance _____
 Muscle movement _____
 Joint movement _____
 Transfer performance _____
 Walking _____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Exercise Therapy: Muscle Control
 Collaborate with physical and occupational therapists
in developing and executing exercise program to
determine extent of problem and plan appropriate
interventions.
 Determine patient’s readiness to engage in activity or
exercise protocol to assess expected level of
participation.
 Apply splints to achieve stability of proximal joints
involved with fine motor skill activities to prevent
contractures.
 Encourage patient to practice exercises independently
to promote patient’s sense of control.
 Reinforce instructions provided to patient about the
proper way to perform exercises to minimize injury and
maximize effectiveness.
 Provide restful environment for patient after periods of
exercise to facilitate recuperation.

Nursing Diagnosis
Impaired Communication
Etiology: Aphasia
Supporting data: Refusal or inability to speak, difficulty forming words and sentences to
express thoughts, inappropriate verbalization

Patient Goals
1. Uses effective oral and written communication techniques
2. Has congruency of verbal and nonverbal communication

Outcomes (NOC) Interventions (NIC) and Rationales

Communication Communication Enhancement: Speech Deficit
 Use of spoken language _____  Provide alternative methods of speech
 Use of written language _____ communication (e.g., writing tablet, flash cards,

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eNursing Care Plan 57-4

Outcomes (NOC) Interventions (NIC) and Rationales

 Use of nonverbal language _____
 Exchanges messages accurately
with others _____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
eye blinking, communication board with pictures
and letters, hand signals or other gestures, and
computer) to aid and promote patient
communication
 Provide positive reinforcement to build self-
esteem and confidence.
 Adjust communication style (i.e., stand in front of
patient when speaking, listen attentively, present
one idea or thought at a time, speak slowly while
avoiding shouting, use written communication, or
solicit caregiver’s or family’s assistance in
understanding patient’s speech) to meet patient’s
needs.
 Maintain structured environment and routines
(i.e., ensure consistent daily schedules, provide
frequent reminders, and provide calendars and
other environmental cues) to promote patient’s
independence and self-care.
 Collaborate with caregiver and/or family and
speech language pathologist or therapist to
develop a plan for effective communication.

Nursing Diagnosis
Unilateral Neglect
Etiology: Visual field cut and loss on one side of body (hemianopsia), brain injury from
cerebrovascular problems
Supporting data: Consistent inattention to stimuli on affected side

Patient Goals
1. Cares for both sides of the body appropriately
2. Uses strategies to minimize unilateral neglect

Outcomes (NOC) Interventions (NIC) and Rationales

Heedfulness of Affected Side
 Acknowledges affected side as
being integral to self _____
 Protects affected side when
positioning _____
 Protects affected side when
ambulating _____
 Performs daily care to affected
side _____
 Arranges environment to
compensate for physical or
Unilateral Neglect Management
 Monitor for abnormal responses to three types of
stimuli: sensory, visual, and auditory to determine
the presence of and degree to which unilateral
neglect exists (e.g., inability to see objects on
affected side, leaving food on a plate that
corresponds to affected side, lack of sensation on
affected side).
 Teach patient to scan from left to right to
visualize the entire environment.
 Position bed in room so that individuals approach

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eNursing Care Plan
Outcomes (NOC)
sensory deficits _____
 Uses visual scanning as a
compensatory strategy _____
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
Nursing Diagnosis
Impaired Urinary System Function
Etiology: Impaired impulse to void or inability to reach toilet or manage tasks of voiding
Supporting data: Loss of urinary control, involuntary loss of urine at unpredictable times
Patient Goals
1. Perceives impulse to void, removes clothing for toileting, and uses toilet
2. Able to urinate when the urge arises or with a timed schedule
Outcomes (NOC)
Urinary Continence
 Recognizes urge to void _____
 Maintains predictable pattern of
voiding _____
 Responds to urge in timely
manner _____
 Starts and stops stream _____
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
 Urine leakage between voidings
_____
 Wets clothing during the day
_____
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57-5
Interventions (NIC) and Rationales
and care for patient on unaffected side.
 Rearrange the environment to use the right or left
visual field; position personal items, television, or
reading materials within view on unaffected side
to compensate for visual field deficits.
 Touch unaffected shoulder when initiating
conversation to attract patient’s attention.
 Gradually move personal items and activity to
affected side as patient demonstrates an ability to
compensate for neglect.
 Include caregiver(s) and/or family member(s) in
rehabilitation process to support the patient’s
efforts and assist with care to promote
reintegration with the whole body.
Interventions (NIC) and Rationales
Urinary Habit Training
 Keep a continence specification record for 3 days
to establish voiding pattern and plan appropriate
interventions.
 Establish interval of initial toileting schedule
(based on voiding pattern and usual routine) to
initiate process of improving bladder functioning
and increased muscle tone.
 Assist patient to toilet and prompt to void at
prescribed intervals to assist patient in adapting
to new toileting schedule.
 Discuss daily record of continence with staff to
provide reinforcement and encourage compliance
with toileting schedule.
 Give positive feedback or positive reinforcement
to patient when he or she voids at scheduled
toileting times, and make no comment when
patient is incontinent, to reinforce desired
behavior.
eNursing Care Plan 57-6

Outcomes (NOC) Interventions (NIC) and Rationales

 Wets clothing or bedding during
night _____

Measurement Scale
1 = Consistently demonstrated
2 = Often demonstrated
3 = Sometimes demonstrated
4 = Rarely demonstrated
5 = Never demonstrated

Nursing Diagnosis
Impaired Nutritional Intake
Etiology: Weakness or paralysis of affected muscles
Supporting data: Drooling, difficulty in swallowing, choking

Patient Goal
Has effective swallowing without choking, coughing, or aspiration

Outcomes (NOC) Interventions (NIC) and Rationales

Swallowing Status Swallowing Therapy
 Maintains food in mouth _____  Collaborate with other members of health care
 Handles oral secretions _____ team (e.g., occupational therapist, speech
 Ability to clear oral cavity _____ pathologist, dietitian) to provide continuity in
patient’s rehabilitative plan.
Measurement Scale  Assist patient to sit in an erect position (as close
1 = Severely compromised to 90 degrees as possible) for feeding/exercise to
2 = Substantially compromised provide optimal position for chewing and
3 = Moderately compromised swallowing without aspirating.
4 = Mildly compromised
 Assist patient to position head in forward flexion
5 = Not compromised
in preparation for swallowing (“chin tuck”).
 Assist patient to maintain sitting position for
 Choking _____
30 minutes after completing meal to prevent
 Coughing _____
regurgitation of food.
 Gagging _____
 Teach patient or caregiver emergency measures
for choking to prevent complications in the home
Measurement Scale
1 = Severe
setting.
2 = Substantial  Check mouth for pocketing of food after eating
3 = Moderate to prevent collection and putrefaction of food
4 = Mild and/or aspiration.
5 = None  Provide mouth care as needed to promote
comfort and oral health.
 Monitor body weight to determine adequacy of
nutritional intake.

Nursing Diagnosis

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eNursing Care Plan 57-7

Disturbed Body Image

Etiology: Actual or perceived loss of function, altered body image
Supporting data: Refusal to take part in self-care, expressions of helplessness and
uselessness

Patient Goals
1. Expresses positive feelings of self-worth
2. Takes part in self-care of affected body parts

Outcomes (NOC) Interventions (NIC) and Rationales

Self-Esteem Self-Esteem Enhancement
 Verbalizations of self-  Monitor patient’s statements of self-worth to
acceptance _____ determine effect of stroke on self-esteem.
 Maintenance of grooming and  Encourage patient to identify strengths to facilitate
hygiene _____ patient’s recognition of intrinsic value.
 Acceptance of self-limitations  Assist in setting realistic goals to achieve higher
_____ self-esteem.
 Description of self _____  Reward or praise patient’s progress toward reaching
 Feelings about self-worth goals.
_____  Encourage increased responsibility for self to
promote sense of satisfaction, independence, and
Measurement Scale control, and to reduce frustrations.
1 = Never positive  Monitor levels of self-esteem over time to determine
2 = Rarely positive stressors or situations that trigger low self-esteem
3 = Sometimes positive and to teach coping mechanisms.
4 = Often positive
5 = Consistently positive

Nursing Diagnosis
Risk for Venous Thromboembolism
Risk factors: Dehydration, immobility

Patient Goal
Has no evidence of venous thromboembolism

Outcomes (NOC) Nursing Interventions and Rationales

Tissue Perfusion Circulatory Care: Venous Insufficiency
 Skin temperature _____  Assess lower extremities for redness, swelling, and
 Peripheral edema _____ pain; increased warmth along path of vein; edema
 Rubor _____ or pain in extremity; chest pain; hemoptysis;
 Pain _____ tachypnea; dyspnea; and restlessness to detect
 Heart rate_____ signs/symptoms of venous thromboembolism or
 Level of consciousness _____ pulmonary embolism
 Administer anticoagulants (e.g., heparin,
Surgical Recovery enoxaparin [Lovenox]) as ordered to decrease clot
 Thrombophlebitis _____ formation.

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eNursing Care Plan 57-8

Outcomes (NOC) Nursing Interventions and Rationales

 Pulmonary embolus ______
Measurement Scale
1 = Severe deviation from normal
range
2 = Substantial deviation from
normal range
3 = Moderate deviation from normal
range
4 = Mild deviation from normal
range
5 = No deviation from normal range
 Encourage early ambulation to maintain muscle
contractions and adequate vascular flow.
 Avoid pressure under knees from bed or pillows to
avoid pressure on veins, constriction of circulation,
or pooling and stasis of blood.
 Apply intermittent pneumatic compression devices,
if ordered, to promote venous circulation and
remove for 1 hr q8-10h to allow for skin
assessment.

ICP, Intracranial pressure; NIH, National Institutes of Health; PaCO2, partial pressure of
carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood; SaO2,
arterial oxygen saturation.

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