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(CEREBROVASCULAR ACCIDENT) NURSING CARE

PLANS

14 Stroke
(Cerebrovascular
Accident) Nursing
Care Plans
UPDATED ON JANUARY 21, 2024
BY MATT VERA BSN, R.N.

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).

Table of Contents
What is Cerebrovascular Accident
(CVA) or Stroke?
Nursing Care Plans and
Management
Nursing Problem Priorities
Nursing Assessment
Nursing Diagnosis
Nursing Goals
Nursing Interventions and
Actions
1. Assessing and Monitoring
Mental Status
2. Improving Physical
Mobility and Preventing
Contractures
3. Managing Aphasia and
Promoting Effective
Communication
4. Managing Post-Stroke
Pain
5. Promoting Effective
Coping Strategies and
Providing Emotional
Support
6. Promoting Independence
Through Self-Care
7. Preventing Dysphagia
and Promoting Effective
Swallowing
8. Managing Fatigue and
Tolerance to Activity
9. Assessing and
Monitoring for Unilateral
Neglect
10. Assessing and
Monitoring for Disuse
Syndrome
11. Promoting Safety and
Preventing Injuries
12. Initiating Patient
Education and Health
Teachings
13. Administer Medications
and Provide Pharmacologic
Support
14. Monitoring Results of
Diagnostic and Laboratory
Procedures
Recommended Resources
See also
References and Sources

What is
Cerebrovascular
Accident (CVA) or
Stroke?
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).

Nursing Care Plans

and Management
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.

Nursing Problem Priorities

The following are the nursing priorities
for patients with CVA:

Recognize and assess signs and

symptoms of stroke.
Activate emergency response and
facilitate immediate medical
intervention.
Monitor and stabilize vital signs
and neurological status.
Coordinate diagnostic imaging,
such as CT or MRI scans, to
confirm the diagnosis and
determine the type of stroke.
Implement time-sensitive
treatments, such as thrombolytic
therapy or mechanical
thrombectomy, if appropriate.
Provide supportive care to
manage complications and
promote recovery, including blood
pressure control and prevention of
secondary brain injury.
Collaborate with healthcare
professionals to develop an
individualized stroke care plan.
Facilitate rehabilitation services,
including physical, occupational,
and speech therapies, to optimize
functional recovery.
Educate patients and caregivers
on stroke risk factors, prevention
strategies, and warning signs of a
recurrent stroke.
Offer emotional support and
counseling to patients and families
during the recovery process.

Nursing Assessment
Assess for the following subjective
and objective data:

See nursing assessment cues

under Nursing Interventions and
Actions.

Nursing Diagnosis
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.

Nursing Goals
Goals and expected outcomes may
include:

The client will maintain the

usual/improved level of
consciousness, cognition, and
motor/sensory function.
The client will demonstrate stable
vital signs and the absence of
signs of increased ICP.
The client will display no further
deterioration/recurrence of
deficits.
The client will maintain/increase
the strength and function of the
affected or compensatory body
part [specify].
The client will maintain the optimal
position of function as evidenced
by the absence of contractures,
and foot drop.
The client will demonstrate
techniques/behaviors that enable
the resumption of activities.
The client will maintain skin
integrity.
The client will indicate an
understanding of the
communication problems.
The client will establish a method
of communication in which needs
can be expressed.
The client will use resources
appropriately.
The client report decrease in pain
[specify with pain scale
assessment].
The client performs activities for
recovery and rehabilitation
The client demonstrates the
absence of side effects from
analgesics
The client will verbalize
acceptance of self in the situation.
The client will talk/communicate
with significant others (SO) about
the situation and changes that
have occurred.
The client will verbalize awareness
of their own coping abilities.
The client will meet psychological
needs as evidenced by
appropriate expression of feelings,
identification of options, and use
of resources.
The client will demonstrate
techniques/lifestyle changes to
meet self-care needs.
The client will perform self-care
activities within the level of their
own ability.
The client will identify
personal/community resources
that can provide assistance as
needed.
The client will participate in
prescribed physical activity with
appropriate changes in heart rate,
blood pressure, and respiratory
rate.
The client will state symptoms of
adverse effects of exercise and
report the onset of symptoms
immediately.
The client will verbalize an
understanding of the need to
gradually increase activity based
on tolerance.
The client will demonstrate
increased tolerance to activity.
The client will acknowledge the
presence of impairment.
The client will demonstrate and
use techniques that can be used
to minimize unilateral neglect.
The client will care for both sides
of the body appropriately and
keep the affected side free from
harm.
The client will return to the
optimized functioning level
possible.
The client will be free from injury.
The client and significant other will
display methods that improve
ambulating and transferring.
The client will not manifest
evidence of shoulder subluxation
or shoulder-hand syndrome.
The client will interact
appropriately with his or her
environment and does not exhibit
evidence of injury caused by
sensory/perceptual deficit.

Nursing Interventions and

Actions
Therapeutic interventions and nursing
actions for patients with cerebrovascular
accident (CVA) may include:

1. Assessing and Monitoring

Mental Status
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).

2. Improving Physical Mobility

and Preventing Contractures
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).

3. Managing Aphasia and

Promoting Effective
Communication
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).

4. Managing Post-Stroke Pain

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).

5. Promoting Effective Coping

Strategies and Providing
Emotional Support
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).

6. Promoting Independence
Through Self-Care
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).

7. Preventing Dysphagia and

Promoting Effective Swallowing
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).

8. Managing Fatigue and

Tolerance to Activity
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).

9. Assessing and Monitoring for

Unilateral Neglect
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:

Neglecting to wash, shave, or

dress one side of the body
Sitting or lying inappropriately on
the affected arm or leg
Failing to respond to
environmental stimuli contralateral
to the side of the lesion
Eating food on only one side of the
plate
Failing to look to one side of the
body
Alteration in safety behavior on
the neglected side
Disturbance of sound
lateralization
Failure to dress neglected side
Failure to eat food from the
portion of the plate on the
neglected side
Failure to groom neglected side
Failure to move body parts (eyes,
head, limbs, trunk) in the
neglected hemisphere
Failure to notice people
approaching from a neglected
side
Hemianopsia

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).

10. Assessing and Monitoring

for Disuse Syndrome
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:

Encourage weight bearing on the

client’s stronger side.
Teach the client to focus on the
stronger side and utilize the
stronger arm as a way to support.
Instruct the client that the
simplest and safest way to
transfer is to go on the unaffected
side.
Teach the client to put the
unaffected side closest to the bed
or chair to which he or she wishes
to transfer.
Instruct the client to place the
affected leg under with the foot
flat on the ground during
transferring.
Place a locked wheelchair or
braced chair near the client’s
stronger side.

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).

11. Promoting Safety and

Preventing Injuries
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).

12. Initiating Patient Education

and Health Teachings
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).

13. Administer Medications and

Provide Pharmacologic Support
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).

14. Monitoring Results of

Diagnostic and Laboratory
Procedures
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
Resources
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
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are ICNP diagnoses, care plans
on LGBTQ health issues, and on
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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
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interventions and an
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Nursing Diagnosis Manual:

Planning, Individualizing, and
Documenting Client Care
Identify interventions to plan,
individualize, and document
care for more than 800 diseases
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See also
Other recommended site resources for
this nursing care plan:

Nursing Care Plans (NCP):

Ultimate Guide and Database
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Over 150+ nursing care plans for

different diseases and conditions.
Includes our easy-to-follow guide
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Nursing Diagnosis Guide and
List: All You Need to Know to
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Our comprehensive guide on how
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care plan guides for common
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neurological disorders:

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Neurological Care Plans, Nursing

Care Plans
Cerebrovascular Accident (CVA) or
Stroke, Deficient Knowledge (Knowledge
Deficit), Disturbed Sensory Perception,
Impaired Physical Mobility, Impaired
Verbal Communication, Ineffective
Coping, Risk for Impaired Swallowing,
Risk for Ineffective Cerebral Tissue
Perfusion, Self-Care Deficit
8 Laminectomy (Disc Surgery)
Nursing Care Plans
Nursing: Treating People Beyond
Medications

Matt Vera BSN, R.N.

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.

22 thoughts on “14 Stroke

(Cerebrovascular Accident)
Nursing Care Plans”

mely
August 25, 2013 at 10:12 AM

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

Rebecca
October 25, 2013 at 2:55 AM

I agree with the comment above!

How can we cite this awesome
website?!
Reply

AB
October 29, 2013 at 10:27 AM

Vera, M. (2013, August 2).

Nursing care plans: 8
cerebrovascular accident
(stroke) nursing care plans.
Retrieved October 24, 2013,
from Nurses labs:
https://nurseslabs.com/8-
cerebrovascular-accident-
stroke-nursing-care-
plans/#Impaired_Verbal_Comm
unication
APA 6th Edition
Reply

AB
October 29, 2013 at 10:29 AM

Make sure to italicize: Nursing

care plans: 8 cerebrovascular
accident (stroke) nursing care
plans.

JH
October 28, 2016 at 11:59 PM

Slight correction on what was

posted:
Vera, M. (2013). 8+
Cerebrovascular Accident
(Stroke) Nursing Care Plans.
Retrieved from
https://nurseslabs.com/8-
cerebrovascular-accident-
stroke-nursing-care-plans/11/
And, as stated, make sure to
italicize the title.
Reply

Lyn
May 21, 2014 at 3:20 PM

Very educational, learnt a lot how

to provide care with a client who
has had a CVA.
Reply

Sabrina
June 20, 2014 at 4:28 AM

Great info! Very helpful.

Reply
Purplebevs
November 30, 2014 at 4:08 PM

very precise and informative.

thank you.
Reply

Osindi Jared
March 10, 2016 at 4:30 AM

Thank you :O had to be my last

concept map ever for nursing
school :)
Reply

Jovi
September 23, 2018 at 7:37 PM

Thanks so much for these

topics,is highly refreshing.
Reply

Vikki
February 26, 2019 at 5:14 AM

Hi. Everything you have here is

super helpful. But, I could figure
out how to put this in in text
citation. Can you help?
Reply

Matt Vera, BSN, R.N.

February 26, 2019 at 6:33 PM

Hello Vikki. Sure. You can use a

tool like bibme.org to make
citations. Just enter the link and
fill up the details. Here, I went
ahead and made you the APA
citation for this study guide:
Vera, M., RN. (2019, February
12). 8 Cerebrovascular
Accident (Stroke) Nursing Care
Plans.
Retrieved from
https://nurseslabs.com/8-
cerebrovascular-accident-
stroke-nursing-care-plans/
Reply

kabu
August 19, 2019 at 2:40 AM

Comment: the information was

precise and helpful. thank you
Reply

Anja
September 26, 2019 at 4:26 PM

Very informative
Reply

Aly
April 17, 2020 at 5:00 AM

I love this site and it has helped

me so much through school, but
I need to address an intervention
here: One should NEVER
massage any reddened areas.
Please fix this
Reply

MATHEWS JOSEPH
June 5, 2020 at 3:13 PM

It’s very helpful .very informative.

Reply

Maricar Quisto
October 15, 2020 at 5:55 PM

Very helpful for nursing students

like me.
Reply

KIMENG DAVID F.
January 11, 2021 at 4:33 AM

I am so impressed by this plan ,

its quite teaching to nursing
students.
Reply

Elma
February 11, 2021 at 1:26 PM

This is better than all the books i

am studying right now im nursing
school. Im on my last year and i
just realised they have never
taught us this stuff. Bookmarking
this page so i can read it after
exams
Reply

ZEPHA
April 1, 2021 at 10:37 PM

Very articulate piece. It has

guided writing my care plans
Reply

Elikem B
August 27, 2021 at 6:08 AM

This site is very educational and

informative! Great work done!
Reply

Abigail
February 23, 2022 at 9:35 AM

Nice visiting this site, it has

helped me a lot in drawing good
care plan.
This source is reliable
Reply

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