Last updated on December 28th, 2023
Here we will formulate sample cerebrovascular accident (CVA/Stroke) nursing care plans based on a hypothetical case scenario.
It will include three CVA/Stroke nursing care plans with NANDA nursing diagnoses, nursing assessment, expected outcome, and nursing interventions with rationales.
Cerebrovascular Accident (CVA/Stroke) Case Scenario
A 73-year old female presents to the ED with complaints of right-sided weakness and difficulty speaking. The patient’s son said he was having lunch with his mom when she began having problems holding her fork and using her right arm. When he asked his mom what was wrong, she had difficulty finding words and was unable to properly formulate sentences. The patient’s son also noticed her face appeared asymmetrical.
Upon assessment, the patient appears drowsy. She is unable to answer orientation questions and engages in endless word-searching, repeating sentences such as – “you… the… the…” The patient is able to obey commands on the left side, but can only minimally move her right arm and leg. She can smile and raise her eyebrows, but her face is asymmetrical and the right side is less mobile than the left. Her gaze is normal and partial hemianopia is noted in the right visual field.
The patient’s blood work is within normal limits. A CT scan of the head is performed, confirming the presence of cerebral infarction.
The patient is admitted to the hospital for a Cerebrovascular Accident (CVA/Stroke).
#1 CVA/Stroke Nursing Care Plan – Ineffective cerebral tissue perfusion
CVA/Stroke Nursing Assessment
Subjective Data:
- The patient is unable to verbally communicate
Objective Data:
- The patient has right-sided weakness, facial asymmetry, and difficulty speaking.
- CT scan confirms the presence of a cerebral infarction
Nursing Diagnosis
Ineffective cerebral tissue perfusion related to hemorrhage or clot in a cerebral vessel as evidenced by right-sided weakness, facial asymmetry, and difficulty speaking
Goal/Desired Outcome
Short-term goal: By the end of the shift the patient will demonstrate an improvement in speaking ability and demonstrate equal bilateral motor strength.
Long-term goal: The patient will return to baseline and experience no residual neurological dysfunction
CVA/Stroke Nursing Interventions with Rationales – Ineffective cerebral tissue perfusion
| Nursing Interventions | Rationales |
| If a hemorrhagic stroke is confirmed, prepare the patient for surgery | A hemorrhagic stroke can be treated by surgery, clipping, or coiling to stop the bleeding and relieve pressure in the brain |
| If an ischemic stroke is confirmed, anticipate starting thrombolytics or preparing for an endovascular procedure | Thrombolytics dissolve the clot and must be started within 4.5 hours of symptoms startingEndovascular procedures include clot retrieval or delivering thrombolytics directly to the site of the clot |
| Perform the NIHSS to monitor for worsening of stroke symptoms | The NIH stroke scale should be performed as frequently as needed (every 15 minutes to once a shift depending on patient status) to monitor neurological status and progression of stroke |
| Monitor vital signs and heart rhythm | Hypertension and atrial fibrillation can increase the likelihood of having a stroke |
| Educate the patient and family about the acronym FAST | FAST is an acronym that identifies the common symptoms of strokes and stresses the importance of seeking medical help as soon as possible. It stands for facial drooping, arm weakness, speech difficulties, and time. |
#2 CVA/Stroke Nursing Care Plan – Risk for aspiration
CVA/Stroke Nursing Assessment
Subjective Data:
- The patient is unable to verbally communicate
Objective Data:
- The patient has right-sided weakness, facial asymmetry, and difficulty speaking
- CT scan confirms the presence of a cerebral infarction
Nursing Diagnosis
Risk for aspiration related to neuromuscular dysfunction secondary to stroke as evidenced by right-sided weakness, facial asymmetry, and difficulty speaking
Goal/Desired Outcome
Short-term goal: The patient will perform oral care and remain NPO for the duration of the shift
Long-term goal: The patient will resume normal eating habits and have no residual swallowing issues
CVA/Stroke Nursing Interventions with Rationales – Risk for aspiration
| Nursing Interventions | Rationales |
| Once stabilized and if appropriate, perform a bedside swallow study | To initially assess swallow function, a bedside swallow study can be performed by the nurse, looking for any signs of aspiration such as choking or coughing |
| For complex cases, refer to a speech pathologist to perform a swallow study | Speech pathologists can perform a more in-depth and thorough swallow assessment |
| Auscultate lung sounds before and after feedings | Adventitious lung sounds after feeding can indicate aspiration |
| Sit the patient up to 90 degrees while eating and keep the head of the bed elevated for an hour after feeding | The patient’s head should be elevated to the highest level that is comfortable to avoid gastric reflux and aspiration |
| When feeding, have suction available and provide ample time for eating | Suction is needed on hand in case of choking or further interventions such as intubation. Eating slowly and deliberately decreases the risk of aspiration. |
#3 CVA/Stroke Nursing Care Plan- Impaired physical mobility
CVA/Stroke Nursing Assessment
Subjective Data:
- The patient’s son noticed she was having trouble holding her fork and using her right arm
Objective Data:
- The patient has right-sided weakness and can only minimally move her right arm and leg
- CT scan confirms the presence of a cerebral infarction
CVA/Stroke Nursing Diagnosis
Impaired physical mobility related to neuromuscular dysfunction secondary to stroke as evidenced by decreased mobility on the right side
Goal/Desired Outcome
Short-term goal: By the end of the shift the patient will demonstrate an improvement in right-sided mobility and remain free from injury
Long-term goal: The patient will successfully demonstrate the use of adaptive equipment to assist with the mobility and performance of ADLs
CVA/Stroke Nursing Interventions with Rationales – Impaired physical mobility
| Nursing Interventions | Rationales |
| Perform a fall risk evaluation and enact the appropriate precautions | Bed alarms and non-skid socks are strategies to avoid falls while the patient is in the hospital, but fall precautions may need to be taken at home as well, such as securing loose rugs or cleaning up clutter |
| Coordinate occupational and physical therapy | Both of these therapies are critical to improving mobility and helping the patient successfully perform activities of daily living |
| Consider constraint-induced movement therapy | This type of therapy can improve the movement of the affected upper extremity by restraining the patient’s strong arm to encourage and force the use of the patient’s weaker arm |
| Provide appropriate mobility assist devices | Depending on the patient’s level of disability, mobility devices such as a cane, walker, or wheelchair may be needed |
| Educate the patient or family about assist devices at home | Some assist devices, such as grab bars or shower chairs, can be helpful to have installed at home |
Conclusion
To conclude, we created scenario-based 3 sample nursing care plans for cerebrovascular accident (CVA/Stroke). These nursing care plans include nursing assessment, NANDA nursing diagnosis, expected outcome, and nursing interventions with rationales for CVA/Stroke.
Reference
Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing Diagnoses Handbook: An Evidence-based Guide to Planning Care (12th ed.). Elsevier.
Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.
Swearingen, P. (2016). ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). Elsevier/Mosby.
