Nursing Care Plans For Stroke

Nursing care plans for stroke are designed to help nurses provide optimal care for patients who have suffered a stroke. The care plans outline specific procedures and interventions that can help prevent complications in stroke patients, including aspiration pneumonia and other infections.

Assess the strength of all extremities.

• Assess the strength of all extremities. This means you will assess the strength of arms, legs, hands and feet as well as the muscles in your face, trunk (torso), abdomen, neck and back.
• Ask questions to determine if any muscle weakness is apparent:
• What color were your hands before they became weak?
• Have you noticed any changes in color happening now?
• How long does it take for your hands to get warm after being cold?
• If there is weakness present in one arm or leg compared with another then you will do a comparison between affected side vs unaffected side; this will help determine if there are differences between affected vs unaffected limbs which would indicate an imbalance within muscles groups that are used together during activities such as walking or running etc..

Monitor peripheral pulses and skin color.

• Monitor peripheral pulses and skin color.
• The patient should have a pulse rate between 60 to 100 beats per minute.
• The patient’s skin color should be pink and warm; dry, cool skin indicates dehydration.

Monitor for paralysis or weakness of muscles in the face, arms and legs.

• Monitor for paralysis or weakness of muscles in the face, arms and legs.
• Check for loss of sensation in all extremities.
• Check for changes in skin color.
• Check for changes in reflexes.
• Check for changes in sensation or deep tendon reflexes on a regular basis. This includes checking temperature, pain, touch and vibration sense as well as proprioception (position sense). These are important because they can indicate nerve damage if impaired or lost completely with a stroke event occurring within the brainstem or cerebral hemispheres respectively.* It is also important to check bladder function along with bowel function daily so that you can monitor how well your patient is able to evacuate their bowels/bladder when needing to do so after having had a stroke episode which might have caused some nerve damage issues related directly towards those two organs being able to function properly without any issues from either side effects from medications given by other medical doctors outside our nursing department here at Memorial Hospital Northside Campus.”

Assess for urinary incontinence; catheterize as needed.

Urinary incontinence is common in stroke patients. Inability to recognize the need to urinate, impaired sphincter control, and paralysis of muscles that help empty the bladder can cause urinary incontinence.

Urinary catheterization is an important aspect of caring for a patient with urinary incontinence. It helps ensure that urine can be drained from the bladder when it becomes full, preventing pain and discomfort. Catheters are available in several sizes and shapes; it’s best to select one that fits comfortably without causing irritation or damage if left in place longer than necessary.

Assess for impaired coordination and fine motor skills (gait, dexterity, eating).

• Assess the patient’s gait.
• Check the patient’s ability to eat (dressing, bathing, grooming, toileting).
• Check the patient’s dexterity skills as needed when taking vital signs or handling dressings.

Monitor respiratory status closely.

You should monitor the patient’s respiratory status closely. This will help to detect signs of respiratory distress, pneumonia or respiratory infection.

• Monitor for signs of aspiration—the aspiration of food or drink into the trachea (windpipe) can occur with a stroke and may lead to airway obstruction. The patient may cough repeatedly, gag continuously, breathe through an open mouth and have no chest movement on one side when you listen with a stethoscope.

Monitor ability to swallow; provide alternative methods of nutrition if necessary.

Monitor ability to swallow; provide alternative methods of nutrition if necessary.

If the patient is unable to swallow safely, use a feeding tube.

Observe behavioral changes, such as disorientation, decreased attention span, irritability, apathy or depression.

• Observe behavioral changes, such as disorientation, decreased attention span, irritability or apathy.
• Evaluate for depression. Observe patient’s mood and behavior for signs of depression (e.g., sad appearance/dressed in drab colors; tearful; withdrawn).
• Refer to mental health professional if patient is depressed (e.g., is suicidal or has a suicide plan). If not depressed refer patient to support group or counseling services as appropriate

Determine patient’s psychiatric status.

Mental status should be assessed at least every shift. A variety of tools are available to assess depression, anxiety and post-stroke depression. The Mini Mental State Examination (MMSE) is one tool that can help determine the patient’s ability to perform basic activities such as eating, dressing and grooming oneself. The Stroke Patient Recovery Scale (SPRS) is another tool that can be used to assess physical function and self-care abilities.

A score 22 suggests good recovery from a stroke event but does not indicate complete functional recovery .

Stroke patients need special care to prevent complications and reduce their risk of another stroke

• Monitor for complications and treat as needed. Stroke patients are at risk of having several complications, including:
• Monitor for depression and treat as needed. Stroke survivors often experience depression after the stroke, which can lead to other problems like low energy, malnutrition and poor sleep quality. Your nurse will determine if your patient is at risk of depression by asking you questions about his or her mood and behavior since the stroke. If your patient is at risk, you may be instructed to refer him or her to a therapist for counseling sessions.
• Monitor for infection and treat as needed. Stroke survivors are vulnerable to infections because their immune systems have been weakened by their strokes—especially in the first year after their strokes occur (the post-acute phase). They’re also less able than usual to fight off infections because they often have trouble exercising normally or using certain muscles that help protect against infection (like those around the mouth). To reduce these risks while helping your loved one heal from a stroke:
• Avoid people who have colds or flu symptoms – Wash your hands frequently with soap and water – Use hand sanitizers when soap isn’t available – If possible, call ahead before visiting anyone who has a cold so they won’t spread it to others

The goal of nursing care is to ensure that stroke patients receive adequate nutrition, hydration and medications. In addition, it is important to prevent complications such as infections and pressure sores. Nurses also need to monitor their psychological status so they can provide appropriate support during this stressful time in their lives.