1.

Impaired Physical Mobility

Assessment:
Conduct a comprehensive assessment of motor function using standardized scales (e.g., the
Brunnstrom stages of motor recovery).
Observe the patient’s ability to move independently, including transfers and ambulation.
Assess for any signs of contractures or muscle weakness in extremities.
Diagnosis:
Impaired physical mobility related to neurological deficits as evidenced by decreased range of
motion and inability to ambulate independently.
Planning:
Patient will demonstrate improved mobility by performing range-of-motion exercises with
assistance within one week.
Patient will ambulate with minimal assistance by discharge.
Intervention:
Assist the patient with passive and active range-of-motion exercises at least twice daily.
Encourage the patient to participate in ambulation sessions, gradually increasing distance as
tolerated.
Use assistive devices (e.g., walkers, canes) as needed to promote safety and independence.
Evaluation:
Reassess mobility levels weekly using standardized scales.
Document improvements in ambulation distance and ability to perform exercises independently.
2. Risk for Aspiration
Assessment:
Perform a swallowing assessment using a speech-language pathologist if available.
Monitor for signs of dysphagia (e.g., coughing during meals, difficulty swallowing).
Evaluate the patient’s ability to manage secretions and maintain an adequate cough reflex.
Diagnosis:
Risk for aspiration related to dysphagia secondary to cerebrovascular accident (CVA).
Planning:
Patient will demonstrate safe swallowing techniques during meals by the end of the week.
Intervention:
Provide thickened liquids and soft foods as recommended by a dietitian.
Position the patient upright during meals and for at least 30 minutes afterward.
Educate the patient and family on safe swallowing strategies (e.g., taking small bites, chewing
thoroughly).
Evaluation:
Monitor for signs of aspiration (e.g., coughing, choking) during meals.
Conduct follow-up assessments with speech therapy to evaluate swallowing improvement.
3. Impaired Communication
Assessment:
Assess speech clarity, comprehension, and ability to express needs verbally.
Use standardized assessments for aphasia if applicable (e.g., Western Aphasia Battery).
Diagnosis:
Impaired verbal communication related to expressive aphasia secondary to stroke.
Planning:
Patient will utilize alternative communication methods effectively (e.g., gestures or
communication boards) within two weeks.
Intervention:
Collaborate with a speech-language pathologist for tailored communication strategies.
Provide communication aids such as picture boards or electronic devices.
Encourage family members to engage in conversation using simple language and yes/no
questions.
Evaluation:
Assess improvement in communication skills through observation and feedback from the patient
and family.
Document any progress in verbal expression or use of alternative communication methods.
4. Acute Pain
Assessment:
Assess pain using a standardized pain scale (0-10) and document location, intensity, duration,
and characteristics.
Diagnosis:
Acute pain related to neurological injury secondary to cerebrovascular accident.
Planning:
Patient will report pain levels below a score of 3/10 within the next two days.
Intervention:
Administer prescribed analgesics promptly and assess their effectiveness after administration.
Implement non-pharmacological pain relief measures such as heat/cold therapy, guided imagery,
or relaxation techniques.
Evaluation:
Reassess pain levels every shift and after interventions.
Document any changes in pain levels and adjust pain management strategies accordingly.
5. Altered Sensory Perception
Assessment:
Conduct sensory assessments focusing on touch, proprioception, vision, and hearing.
Diagnosis:
Altered sensory perception related to neurological damage from stroke as evidenced by
decreased sensation in extremities.
Planning:
Patient will demonstrate improved sensory awareness by identifying stimuli accurately within
four weeks.
Intervention:
Provide sensory stimulation activities such as textured materials or varied temperature stimuli.
Educate the patient about safety measures regarding altered sensations (e.g., hot surfaces).
Evaluation:
Monitor sensory responses weekly through formal assessments or informal observations during
activities.
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6. Risk for Impaired Skin Integrity
Assessment:
Inspect skin condition daily for redness, breakdown, or pressure ulcers; assess risk factors such
as immobility and nutritional status.
Diagnosis:
Risk for impaired skin integrity related to immobility and decreased sensation.
Planning:
Patient will remain free from pressure ulcers throughout hospitalization.
Intervention:
Reposition the patient every two hours; use pillows or cushions to relieve pressure areas.
Implement a skin care regimen that includes moisturizing dry areas and keeping skin clean.
Evaluation:
Conduct daily skin assessments; document any changes in skin integrity or development of
pressure ulcers.
7. Ineffective Coping
Assessment:
Assess emotional responses to stroke diagnosis through interviews or standardized tools (e.g.,
Beck Depression Inventory).
Diagnosis:
Ineffective coping related to sudden lifestyle changes post-stroke as evidenced by verbal
expressions of anxiety or sadness.
Planning:
Patient will verbalize effective coping strategies by discharge.
Intervention:
Provide emotional support through active listening and therapeutic communication techniques.
Facilitate access to counseling services or support groups for stroke survivors and their families.
Evaluation:
Assess coping strategies utilized at follow-up appointments; document improvements in
emotional well-being over time.
8. Deficient Knowledge about Stroke Management
Assessment:
Evaluate patient’s current knowledge regarding stroke risk factors, symptoms, and management
strategies through discussion or quizzes.
Diagnosis:
Deficient knowledge related to lack of education on stroke care as evidenced by questions
regarding post-stroke management.
Planning:
Patient will demonstrate understanding of stroke prevention strategies before discharge.
Intervention:
Provide educational materials on stroke risk factors and prevention methods tailored to the
patient's comprehension level.
Conduct teaching sessions that include discussions about lifestyle modifications (dietary
changes, exercise).
Evaluation:
Conduct a teach-back session before discharge to assess understanding; adjust educational
approaches based on patient feedback.
9. Risk for Falls
Assessment:
Assess balance, coordination, strength, and environmental hazards in the patient's room (e.g.,
cluttered pathways).
Diagnosis:
Risk for falls related to impaired mobility and strength deficits secondary to cerebrovascular
accident.
Planning:
Patient will remain free from falls during hospitalization.
Intervention:
Implement fall precautions such as bed alarms, non-slip socks, and ensuring call lights are within
reach.
Educate patients on safe transfer techniques and encourage use of assistive devices when
ambulating.
Evaluation:
Review fall incident reports weekly; reassess fall risk based on mobility improvements or
declines during hospitalization.
10. Self-Care Deficit in Activities of Daily Living (ADLs)
Assessment:
Evaluate the patient's ability to perform ADLs independently through observation during
morning care routines.
Diagnosis:
Self-care deficit related to physical limitations from stroke effects as evidenced by requiring
assistance with bathing, dressing, or feeding.
Planning:
Patient will participate in ADLs with minimal assistance by discharge.
Intervention:
Assist with ADLs while encouraging independence; provide adaptive equipment as necessary
(e.g., long-handled reachers).
Set achievable goals for self-care tasks each day; celebrate successes to boost confidence.
Evaluation:
Monitor self-care performance at each nursing shift; document progress towards independence in
ADLs at follow-up visits.