Here we will formulate sample cerebrovascular accident (CVA/Stroke) nursing care plans based on a hypothetical case scenario.
It will include three CVA/Stroke nursing care plans with NANDA nursing diagnoses, nursing assessment, expected outcome, and nursing interventions with rationales.
A 73-year old female presents to the ED with complaints of right-sided weakness and difficulty speaking. The patient’s son said he was having lunch with his mom when she began having problems holding her fork and using her right arm. When he asked his mom what was wrong, she had difficulty finding words and was unable to properly formulate sentences. The patient’s son also noticed her face appeared asymmetrical.
Upon assessment, the patient appears drowsy. She is unable to answer orientation questions and engages in endless word-searching, repeating sentences such as – “you… the… the…” The patient is able to obey commands on the left side, but can only minimally move her right arm and leg. She can smile and raise her eyebrows, but her face is asymmetrical and the right side is less mobile than the left. Her gaze is normal and partial hemianopia is noted in the right visual field.
The patient’s blood work is within normal limits. A CT scan of the head is performed, confirming the presence of cerebral infarction.
The patient is admitted to the hospital for a Cerebrovascular Accident (CVA/Stroke).
Subjective Data:
Objective Data:
Ineffective cerebral tissue perfusion related to hemorrhage or clot in a cerebral vessel as evidenced by right-sided weakness, facial asymmetry, and difficulty speaking
Short-term goal: By the end of the shift the patient will demonstrate an improvement in speaking ability and demonstrate equal bilateral motor strength.
Long-term goal: The patient will return to baseline and experience no residual neurological dysfunction
| Nursing Interventions | Rationales |
| If a hemorrhagic stroke is confirmed, prepare the patient for surgery | A hemorrhagic stroke can be treated by surgery, clipping, or coiling to stop the bleeding and relieve pressure in the brain |
| If an ischemic stroke is confirmed, anticipate starting thrombolytics or preparing for an endovascular procedure | Thrombolytics dissolve the clot and must be started within 4.5 hours of symptoms startingEndovascular procedures include clot retrieval or delivering thrombolytics directly to the site of the clot |
| Perform the NIHSS to monitor for worsening of stroke symptoms | The NIH stroke scale should be performed as frequently as needed (every 15 minutes to once a shift depending on patient status) to monitor neurological status and progression of stroke |
| Monitor vital signs and heart rhythm | Hypertension and atrial fibrillation can increase the likelihood of having a stroke |
| Educate the patient and family about the acronym FAST | FAST is an acronym that identifies the common symptoms of strokes and stresses the importance of seeking medical help as soon as possible. It stands for facial drooping, arm weakness, speech difficulties, and time. |
Subjective Data:
Objective Data:
Risk for aspiration related to neuromuscular dysfunction secondary to stroke as evidenced by right-sided weakness, facial asymmetry, and difficulty speaking
Short-term goal: The patient will perform oral care and remain NPO for the duration of the shift
Long-term goal: The patient will resume normal eating habits and have no residual swallowing issues