A stroke interrupts blood flow to part of the brain. Early care protects the brain. Later care prevents complications like aspiration and falls and supports recovery.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Risk for Ineffective Cerebral Tissue Perfusion
Related to
- Blocked or bleeding blood vessel in the brain
- High blood pressure, atrial fibrillation
As evidenced by
- (Risk diagnosis)
Short-term goals
- Neuro checks stay stable or improve
Long-term goals
- Client reaches the highest possible level of function
- Neuro checks and NIH Stroke Scale as ordered
- Blood pressure within ordered limits
- Last known well time
| INTERVENTION | RATIONALE |
|---|---|
| Get a CT scan without contrast right away | Rules out bleeding before clot-busting drugs. |
| Keep blood pressure within the ordered range | Protects brain perfusion and lowers bleeding risk. |
| Report any change in neuro status immediately | A change can mean the stroke is extending. |
EVALUATION
- Neuro checks are stable
- No new deficits
CARE PLAN 2 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Risk for Aspiration
Related to
- Weak swallow (dysphagia)
- Facial weakness
As evidenced by
- (Risk diagnosis)
Short-term goals
- Client has no signs of aspiration during the stay
Long-term goals
- Client eats safely with the right diet texture
- Swallow screen before any food, fluid, or pills
- Lung sounds and temperature
| INTERVENTION | RATIONALE |
|---|---|
| Keep NPO until the swallow screen is passed | Prevents choking and aspiration pneumonia. |
| Sit upright at 90 degrees for meals and 30 minutes after | Gravity protects the airway. |
| Use thickened liquids if ordered and teach chin tuck | Slows liquid and protects the airway. |
EVALUATION
- Lungs stay clear and temperature normal
Practice this in SBAR Shift Master
Take report on a new stroke and pick the priority actions.
Play SBAR Shift MasterQuick answers
What must happen before a stroke client eats?
A swallow screen. Keep the client NPO, including pills, until they pass.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.