nursing case study stroke patient

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

This case study presents a 68-year old “right-handed” African-American man named Randall Swanson. He has a history of hypertension, hyperlipidemia and a history of smoking one pack per day for the last 20 years. He is prescribed Atenolol for his HTN, and Simvastatin for Hyperlipidemia (but he has a history of not always taking his meds). His father had a history of hypertension and passed away from cancer 10 years ago. His mother has a history of diabetes and is still alive.

Randall was gardening with his wife on a relaxing Sunday afternoon. Out of nowhere, Randall fell to the ground. When his wife rushed to his side and asked how he was doing, he answered with garbled and incoherent speech. It was then that his wife noticed his face was drooping on the right side. His wife immediately called 911 and paramedics arrived within 6 minutes. Upon initial assessment, the paramedics reported that Randall appeared to be experiencing a stroke as he presented with right-sided facial droop and weakness and numbness on the right side of his body. Fortunately, Randall lived nearby a stroke center so he was transported to St. John’s Regional Medical Center within 17 minutes of paramedics arriving to his home.

Initial Managment

Upon arrival to the Emergency Department, the healthcare team was ready to work together to diagnose Randall. He was placed in bed with the HOB elevated to 30 degrees to decrease intracranial pressure and reduce any risks for aspiration. Randall’s wife remained at his side and provided the care team with his brief medical history which as previously mentioned, consists of hypertension, hyperlipidemia and smoking one pack per day for the last 20 years. He had no recent head trauma, never had a stroke, no prior surgeries, and no use of anticoagulation medications.

Physical Assessment

Upon first impression, Nurse Laura recognized that Randall was calm but looked apprehensive. When asked to state his name and date of birth, his speech sounded garbled at times and was very slow, but he could still be understood. He could not recall the month he was born in but he was alert and oriented to person, time, and situation. When asked to state where he was, he could not recall the word hospital. He simply pointed around the room while repeating “here.”

Further assessment revealed that his pupils were equal and reactive to light and that he presented with right-sided facial paralysis. Randall was able to follow commands but when asked to move his extremities, he could not lift his right arm and leg. He also reported that he could not feel the nurse touch his right arm and leg. Nurse Laura gathered the initial vital signs as follows: BP: 176/82, HR: 93, RR: 20, T:99.4, O2: 92% RA and a headache with pain of 3/10.

Doctor’s Orders

The doctor orders were quickly noted and included:

-2L O2 (to keep O2 >93%)

– 500 mL Bolus NS

– VS Q2h for the first 8 hrs.

-Draw labs for: CBC, INR, PT/INR, PTT, and Troponin

-Get an EKG

-Chest X ray

-Glucose check

-Obtain patient weight

-Perform a National Institute of Health Stroke Scale (also known as NIHSS) Q12h for the first 24 hours, then Q24h until he is discharged

-Notify pharmacy of potential t-PA preparation.

Nursing Actions

Nurse Laura started an 18 gauge IV in Randall’s left AC and started him on a bolus of 500 mL of NS. A blood sample was collected and quickly sent to the lab. Nurse Laura called the Emergency Department Tech to obtain a 12 lead EKG.

Pertinent Lab Results for Randall

The physician and the nurse review the labs:

WBC 7.3 x 10^9/L

RBC 4.6 x 10^12/L

Plt 200 x 10^9/L

LDL 179 mg/dL

HDL 43 mg/dL

Troponin <0.01 ng/mL

EKG and Chest X Ray Results

The EKG results and monitor revealed Randall was in normal sinus rhythm; CXR was negative for pulmonary or cardiac pathology

CT Scan and NIHSS Results 

The NIH Stroke Scale was completed and demonstrated that Randall had significant neurological deficits with a score of 13. Within 20 minutes of arrival to the hospital, Randall had a CT-scan completed. Within 40 minutes of arrival to the hospital, the radiologist notified the ED physician that the CT-scan was negative for any active bleeding, ruling our hemorrhagic stroke.

The doctors consulted and diagnosed Randall with a thrombotic ischemic stroke and determined that that plan would include administering t-PA. Since Randall’s CT scan was negative for a bleed and since he met all of the inclusion criteria he was a candidate for t-PA. ( Some of the inclusion criteria includes that the last time the patient is seen normal must be within 3 hours, the CT scan has to be negative for bleeding, the patient must be 18 years or older, the doctor must make the diagnosis of an acute ischemic stroke, and the patient must continue to present with neurological deficits.)

Since the neurologist has recommended IV t-PA, the physicians went into Randall’s room and discussed what they found with him and his wife. Nurse Laura answered and addressed any remaining concerns or questions.

Administration

Randall and his wife decided to proceed with t-PA therapy as ordered, therefore Nurse Laura initiated the hospital’s t-PA protocol. A bolus of 6.73 mg of tPA was administered for 1 minute followed by an infusion of 60.59 mg over the course of 1 hour. ( This was determined by his weight of 74.8 kg).  After the infusion was complete, Randall was transferred to the ICU for close observation. Upon reassessment of the patient, Randall still appeared to be displaying neurological deficits and his right-sided paralysis had not improved. His vital signs were assessed and noted as follows: BP: 149/79 HR: 90 RR: 18 T:98.9 O2: 97% 2L NC Pain: 2/10.

Randall’s wife was crying and he appeared very scared, so Nurse John tried to provide as much emotional support to them as possible. Nurse John paid close attention to Randall’s blood pressure since he could be at risk for hemorrhaging due to the medication. Randall was also continually assessed for any changes in neurological status and allergic reactions to the t-PA. Nurse John made sure that Stroke Core Measures were followed in order to enhance Randall’s outcome.

In the ICU, Randall’s neurological status improved greatly. Nurse Jan noted that while he still garbled speech and right-sided facial droop, he was now able to recall information such as his birthday and he could identify objects when asked. Randall was able to move his right arm and leg off the bed but he reported that he was still experiencing decreased sensation, right-sided weakness and he demonstrated drift in both extremities.

The nurse monitored Randall’s blood pressure and noted that it was higher than normal at 151/83. She realized this was an expected finding for a patient during a stroke but systolic pressure should be maintained at less than 185 to lower the risk of hemorrhage. His vitals remained stable and his NIHSS score decreased to an 8. Labs were drawn and were WNL with the exception of his LDL and HDL levels. His vital signs were noted as follows: BP 151/80 HR 92 RR 18 T 98.8 O2 97% RA Pain 0/10

The Doctor ordered Physical, Speech, and Occupational therapy, as well as a swallow test.

Swallowing Screen

Randall remained NPO since his arrival due to the risks associated with swallowing after a stroke. Nurse Jan performed a swallow test by giving Randall 3 ounces of water. On the first sip, Randall coughed and subsequently did not pass. Nurse Jan kept him NPO until the speech pathologist arrived to further evaluate Randall. Ultimately, the speech  pathologist determined that with due caution, Randall could be put on a dysphagia diet that featured thickened liquids

Physical Therapy & Occupational Therapy

A physical therapist worked with Randall and helped him to carry out passive range of motion exercises. An occupational therapist also worked with Randall to evaluate how well he could perform tasks such as writing, getting dressed and bathing. It was important for these therapy measures to begin as soon as possible to increase the functional outcomes for Randall. Rehabilitation is an ongoing process that begins in the acute setting.

Day 3- third person 

During Day 3, Randall’s last day in the ICU, Nurse Jessica performed his assessment. His vital signs remained stable and WNL as follows: BP: 135/79 HR: 90 RR: 18 T: 98.9 O2: 97% on RA, and Pain 0/10. His NIHSS dramatically decreased to a 2. Randall began showing signs of improved neurological status; he was able to follow commands appropriately and was alert and oriented x 4. The strength  in his right arm and leg markedly improved. he was able to lift both his right arm and leg well and while he still reported feeling a little weakness and sensory loss, the drift in both extremities was absent.

Rehabilitation Therapies

Physical, speech, and occupational therapists continued to work with Randall. He was able to call for assistance and ambulate with a walker to the bathroom and back. He was able to clean his face with a washcloth, dress with minimal assistance, brush his teeth, and more. Randall continued to talk with slurred speech but he was able to enunciate with effort.

On day 4, Randall was transferred to the med-surg floor to continue progression. He continued to work with physical and occupational therapy and was able to perform most of his ADLs with little assistance. Randall could also ambulate 20 feet down the hall with the use of a walker.

Long-Term Rehabilitation and Ongoing Care

On day 5, Randall was discharged to a rehabilitation facility and continued to display daily improvement. The dysphagia that he previously was experiencing resolved and he was discharged home 1.5 weeks later. Luckily for Randall, his wife was there to witness his last known well time and she was able to notify first responders. They arrived quickly and he was able to receive t-PA in a timely manner. With the help of the interdisciplinary team consisting of nurses, therapists, doctors, and other personnel, Randall was put on the path to not only recover from the stroke but also to quickly regain function and quality of life very near to pre-stroke levels. It is now important that Randall continues to follow up with his primary doctor and his neurologist and that he adheres to his medication and physical therapy regimen.

Case Management

During Randall’s stay, Mary the case manager played a crucial role in Randall’s path to recovery. She determined that primary areas of concern included his history of medical noncompliance and unhealthy lifestyle. The case manager consulted with Dietary and requested that they provide Randall with education on a healthy diet regimen. She also provided him with smoking cessation information. Since Randall has been noncompliant with his medications, Mary determined that social services should consult with him to figure out what the reasons were behind his noncompliance. Social Services reported back to Mary that Randall stated that he didn’t really understand why he needed to take the medication. It was apparent that he had not been properly educated. Mary also needed to work with Randall’s insurance to ensure that he could go to the rehab facility as she knew this would greatly impact his ultimate outcome. Lastly, throughout his stay, the case manager provided Randall and his wife with resources on stroke educational materials. With the collaboration of nurses, education on the benefits of smoking cessation, medication adherence, lifestyle modifications, and stroke recognition was reiterated to the couple. After discharge, the case manager also checked up with Randall to make sure that he complied with his follow up appointments with the neurologist and physical and speech therapists,

• What risk factors contributed to Randall’s stroke?
• What types of contraindications could have prevented Randall from receiving t-PA?
• What factors attributed to Randall’s overall favorable outcome?

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

Share This Book

Stroke Case Study (45 min)

Watch More! Unlock the full videos with a FREE trial

Included In This Lesson

Study tools.

Access More! View the full outline and transcript with a FREE trial

Mrs. Blossom is a 57-year-old female who presented to the Emergency Room with new onset Atrial Fibrillation with Rapid Ventricular Response (RVR). She is admitted to the cardiac telemetry unit after being converted to normal sinus rhythm with a calcium channel blocker (diltiazem). When you enter the room to assess Mrs. Blossom, her daughter looks at you concerned and says “mom’s acting kinda funny.”

What nursing assessments should be completed at this time?

• Full set of vital signs (Temp, HR, BP, RR, SpO2)
• Should probably get a 12-lead EKG
• Assess symptoms using PQRST or OLDCARTS

You assess Mrs. Blossom to find she has a left sided facial droop, slurred speech, and is unable to hold her left arm up for more than 3 seconds.

What is/are your priority nursing action(s) at this time?

• Call a Code Stroke (or whatever the equivalent is at your facility) to initiate response of the neurologist or Stroke team.
• Notify the charge nurse to help you obtain emergency equipment if you don’t already have it at the bedside to be prepared in case of emergency

What may be occurring in Mrs. Blossom?

• She may be having a stroke

You call a Code Stroke and notify the charge nurse for help. You obtain suction to have at bedside just in case. The neurologist arrives at bedside within 7 minutes to assess Mrs. Blossom. He notes her NIH Stroke Scale score is 32. He orders a STAT CT scan, which shows there is no obvious bleed in the brain.

What are the possible interventions for Mrs. Blossom at this time?

• Since there is no bleed evident on scan, Mrs. Blossom would qualify for a thrombolytic like tPA (alteplase) or for surgical intervention, as long as there are no contraindications

What are the contraindications for thrombolytics like tPA (alteplase)?

• Recent surgery, current or recent GI bleed within the last 3 months, excessive hypertension, evidence of cerebral hemorrhage

You administer tPA per protocol, initiate q15min vital signs and neuro checks. You stay with the patient to continue to monitor her symptoms.

What are possible complications of tPA administration? What should you monitor for?

• Bleeding, especially into the brain or a GI bleed
• She may bruise easily or bleed from IV sites or her gums
• Monitor for s/s bleeding or worsening stroke symptoms, which may indicate a hemorrhagic stroke has developed.

After 2 hours, Mrs. Blossom is showing signs of improvement. She is able to speak more clearly, though with a slight slur. She is still slightly weak on the left side, but is able to hold her arm up for 10 seconds now. Her NIHSS is now 6. Mrs. Blossom’s daughter asks you why this happened.

What would you explain has happened to Mrs. Blossom physiologically?

• Because of her new onset atrial fibrillation, the blood was likely pooling in her atria because they were just quivering and not contracting. When blood pools, it clots. When she was converted back into a normal rhythm and her atria began contracting again, that likely dislodged a clot, which went to her brain.
• The clot in her brain caused brain tissue to die → ischemic stroke.

Two days later, Mrs. Blossom has recovered fully. She will be discharged today on Clopidogrel and Aspirin, plus a calcium channel blocker,  with a follow up appointment in 1 week to see the neurologist.

What education topics should be included in the discharge teaching for Mrs. Blossom and her family?

• Anticoagulant therapy is imperative to prevent further clots from forming within Mrs. Blossom’s atria if she stays in Atrial Fibrillation.
• They should be taught the signs of a stroke (FAST) and call 911 if they notice them.
• They should be taught signs of Atrial Fibrillation with RVR and be sure to go to the hospital if this occurs – the patient is at higher risk for stroke.
• Medication instructions for calcium channel blockers and anticoagulants.

View the FULL Outline

When you start a FREE trial you gain access to the full outline as well as:

• SIMCLEX (NCLEX Simulator)
• 6,500+ Practice NCLEX Questions
• 2,000+ HD Videos
• 300+ Nursing Cheatsheets

“Would suggest to all nursing students . . . Guaranteed to ease the stress!”

Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
• 7 Questions
• 5 Questions
• 4 Questions

GI/GU Nursing Case Studies

• 2 Questions
• 8 Questions

Obstetrics Nursing Case Studies

Respiratory nursing case studies.

• 10 Questions

Pediatrics Nursing Case Studies

• 3 Questions
• 12 Questions

Neuro Nursing Case Studies

Mental health nursing case studies.

• 9 Questions

Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.

Explore prestigious scientific journals and award and funding opportunities to advance your research.

Access practice-improvement tools, including guidelines, measures, Axon Registry, and practice management resources.

Learn to effectively advocate on behalf of neurologists and their patients, and access AAN position and policy statements.

Loading... please wait

We’re experiencing unusually high levels of traffic. Thank you for your patience.

Inpatient Stroke Case Studies

Inpatient e/m case studies.

Case study of a stroke patient at varying visit levels to better understand code selection for inpatient encounters under the revised guidelines for 2024.

67-year-old Female with Stroke

Total time* for Inpatient E/M in 2023

Refer to the following tables for correct code selection when billing based on time for inpatient E/M Services:

*Total time includes non face-to-face time on the date of service

Day 1: Critical Care (99291)

A 67-year-old woman with hypertension and diabetes presents to the emergency department with abrupt onset of left hemiparesis 45 minutes ago.

Pre-evaluation : Discussed presentation and vital signs with ED provider (3 mins).

Face-to-face evaluation : Performed medically appropriate history and exam. She has a dense left hemiparesis and an NIH Stroke Scale score of 8. Thrombolysis safety criteria reviewed (7 mins).

Post-evaluation : Non-contrast head CT, CTA of head and neck, and lab results reviewed in the ED. Case discussed with ED provider and thrombolysis recommended. Consultation documented in the ED (25 mins).

Total time : 35 minutes.

Critical Care Coding

According to the 2024 CPT code set, a provider may bill for critical care when the following requirements are met:

• A critical condition: one that acutely impairs a vital organ system with a high probability of imminent or life-threatening deterioration. This includes, for example, central nervous system failure.
• Direct delivery of critical care: high complexity decision-making to assess, manipulate, and support vital systems to treat organ system failure or prevent further life-threatening deterioration.
• At least 30 minutes of time spent solely in the care of the patient. It does not need to be continuous, and it includes both time at the bedside and time spent on the same floor or unit engaged in work directly related to the patient’s care (e.g., documenting critical care, reviewing test results, discussing care with other providers, obtaining history, or discussing treatments or treatment limitations with surrogates when the patient lacks the capacity to do so).

Specific critical care credentials are not required to bill critical care. Critical care is usually provided in a critical care area such as an intensive care unit or emergency department, but this is not always the case (for example, critical care provided to a deteriorating patient in a non-critical care unit).

Other examples of critical care might include:

• Evaluating a patient with status epilepticus and prescribing anti-epileptic drugs or sedative infusions,
• Evaluating a patient with acute respiratory failure from neuromuscular disease and prescribing plasmapheresis,
• Evaluating a patient with coma after cardiac arrest and discussing prognosis, treatment, and goals of care with surrogates (documenting the patient’s lack of capacity to participate)

Critical care, 30-74 minutes CPT 99291 is justified based on the above documentation, although E&M codes (e.g., 99223) associated with fewer wRVUs and lower reimbursement could be used as well.

Day 2: Subsequent Hospital Inpatient Care

Pre-rounds : Reviewed vitals, labs, and studies (LDL, Hemoglobin A1c, EKG, TTE). Review and document independent interpretation of MRI (8 mins).

On Rounds : Performed medically appropriate history and exam. The patient’s symptoms and findings improved somewhat overnight. Patient counseled about stroke evaluation and secondary prevention (10 mins).

Post-rounds : Order atorvastatin, order diabetes consult for management of diabetes. Document discussion with case management possible need for acute inpatient rehabilitation. Documentation completed (10 mins).

Total time : 28 minutes

In this situation, billing according to MDM would be associated with higher reimbursement.

Day 3: Discharge Day Management (By Primary Service)

Pre-rounds : Reviewed vitals, daily CBC and BMP, nursing notes and PT/OT notes (5 mins).

On Rounds : Performed medically appropriate history and exam. The patient reports continued slight improvement in symptoms and requests counseling on how complementary and alternative medicine might help manage her chronic conditions (15 mins).

Post-rounds : Prescribe antiplatelet agent, antidiabetic medications, and antihypertensives. Prepare discharge paperwork and document discharge summary (15 mins).

Total time : 35 minutes

Discharge Day Management Coding (Inpatient or Observation)

Discharge CPTs are selected based on total (face-to-face and non-face-to-face) time, not MDM:

• 99238: 30 minutes or less
• 99239: 31 minutes or more

Discharge CPTs would be used by the primary attending service (e.g., a Neurohospitalist service). Consulting services would continue to choose Subsequent Day codes based on time or MDM.

Discharge Day Management, 31 minutes or more   CPT 99239  

Disclaimer: The billing and coding information provided by the American Academy of Neurology and its affiliates (collectively, “Academy”) are assessments of clinical information provided as an educational service. The information (1) is not clinical advice; (2) does not account for how private payers cover and reimburse procedures or services*; (3) is not continually updated and may not reflect the most current clinical information (new clinical information may emerge between the time information is developed and when it is published or read); and (4) is not a substitute for the independent professional judgment of the treating provider, who is responsible for correctly coding procedures and services.

Using this information is voluntary. The Academy is providing the information on an “as is” basis and makes no warranty, expressed or implied, regarding the information. The Academy specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. The Academy assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.

*The Academy recommends always checking private payer policies before rendering procedures or services

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMJ Case Rep

Case report

Clinical course of a 66-year-old man with an acute ischaemic stroke in the setting of a covid-19 infection, saajan basi.

1 Department of Stroke and Acute Medicine, King's Mill Hospital, Sutton-in-Ashfield, UK

2 Department of Acute Medicine, University Hospitals of Derby and Burton, Derby, UK

Mohammad Hamdan

Shuja punekar.

A 66-year-old man was admitted to hospital with a right frontal cerebral infarct producing left-sided weakness and a deterioration in his speech pattern. The cerebral infarct was confirmed with CT imaging. The only evidence of respiratory symptoms on admission was a 2 L oxygen requirement, maintaining oxygen saturations between 88% and 92%. In a matter of hours this patient developed a greater oxygen requirement, alongside reduced levels of consciousness. A positive COVID-19 throat swab, in addition to bilateral pneumonia on chest X-ray and lymphopaenia in his blood tests, confirmed a diagnosis of COVID-19 pneumonia. A proactive decision was made involving the patients’ family, ward and intensive care healthcare staff, to not escalate care above a ward-based ceiling of care. The patient died 5 days following admission under the palliative care provided by the medical team.

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is a new strain of coronavirus that is thought to have originated in December 2019 in Wuhan, China. In a matter of months, it has erupted from non-existence to perhaps the greatest challenge to healthcare in modern times, grinding most societies globally to a sudden halt. Consequently, the study and research into SARS-CoV-2 is invaluable. Although coronaviruses are common, SARS-CoV-2 appears to be considerably more contagious. The WHO figures into the 2003 SARS-CoV-1 outbreak, from November 2002 to July 2003, indicate a total of 8439 confirmed cases globally. 1 In comparison, during a period of 4 months from December 2019 to July 2020, the number of global cases of COVID-19 reached 10 357 662, increasing exponentially, illustrating how much more contagious SARS-CoV-2 has been. 2

Previous literature has indicated infections, and influenza-like illness have been associated with an overall increase in the odds of stroke development. 3 There appears to be a growing correlation between COVID-19 positive patients presenting to hospital with ischaemic stroke; however, studies investigating this are in progress, with new data emerging daily. This patient report comments on and further characterises the link between COVID-19 pneumonia and the development of ischaemic stroke. At the time of this patients’ admission, there were 95 positive cases from 604 COVID-19 tests conducted in the local community, with a predicted population of 108 000. 4 Only 4 days later, when this patient died, the figure increased to 172 positive cases (81% increase), illustrating the rapid escalation towards the peak of the pandemic, and widespread transmission within the local community ( figure 1 ). As more cases of ischaemic stroke in COVID-19 pneumonia patients arise, the recognition and understanding of its presentation and aetiology can be deciphered. Considering the virulence of SARS-CoV-2 it is crucial as a global healthcare community, we develop this understanding, in order to intervene and reduce significant morbidity and mortality in stroke patients.

A graph showing the number of patients with COVID-19 in the hospital and in the community over time.

Case presentation

A 66-year-old man presented to the hospital with signs of left-sided weakness. The patient had a background of chronic obstructive pulmonary disease (COPD), atrial fibrillation and had one previous ischaemic stroke, producing left-sided haemiparesis, which had completely resolved. He was a non-smoker and lived in a house. The patient was found slumped over on the sofa at home on 1 April 2020, by a relative at approximately 01:00, having been seen to have no acute medical illness at 22:00. The patients’ relative initially described disorientation and agitation with weakness noted in the left upper limb and dysarthria. At the time of presentation, neither the patient nor his relative identified any history of fever, cough, shortness of breath, loss of taste, smell or any other symptoms; however, the patient did have a prior admission 9 days earlier with shortness of breath.

The vague nature of symptoms, entwined with considerable concern over approaching the hospital, due to the risk of contracting COVID-19, created a delay in the patients’ attendance to the accident and emergency department. His primary survey conducted at 09:20 on 1 April 2020 demonstrated a patent airway, with spontaneous breathing and good perfusion. His Glasgow Coma Scale (GCS) score was 15 (a score of 15 is the highest level of consciousness), his blood glucose was 7.2, and he did not exhibit any signs of trauma. His abbreviated mental test score was 7 out of 10, indicating a degree of altered cognition. An ECG demonstrated atrial fibrillation with a normal heart rate. His admission weight measured 107 kg. At 09:57 the patient required 2 L of nasal cannula oxygen to maintain his oxygen saturations between 88% and 92%. He started to develop agitation associated with an increased respiratory rate at 36 breaths per minute. On auscultation of his chest, he demonstrated widespread coarse crepitation and bilateral wheeze. Throughout he was haemodynamically stable, with a systolic blood pressure between 143 mm Hg and 144 mm Hg and heart rate between 86 beats/min and 95 beats/min. From a neurological standpoint, he had a mild left facial droop, 2/5 power in both lower limbs, 2/5 power in his left upper limb and 5/5 power in his right upper limb. Tone in his left upper limb had increased. This patient was suspected of having COVID-19 pneumonia alongside an ischaemic stroke.

Investigations

A CT of his brain conducted at 11:38 on 1 April 2020 ( figure 2 ) illustrated an ill-defined hypodensity in the right frontal lobe medially, with sulcal effacement and loss of grey-white matter. This was highly likely to represent acute anterior cerebral artery territory infarction. Furthermore an oval low-density area in the right cerebellar hemisphere, that was also suspicious of an acute infarction. These vascular territories did not entirely correlate with his clinical picture, as limb weakness is not as prominent in anterior cerebral artery territory ischaemia. Therefore this left-sided weakness may have been an amalgamation of residual weakness from his previous stroke, in addition to his acute cerebral infarction. An erect AP chest X-ray with portable equipment ( figure 3 ) conducted on the same day demonstrated patchy peripheral consolidation bilaterally, with no evidence of significant pleural effusion. The pattern of lung involvement raised suspicion of COVID-19 infection, which at this stage was thought to have provoked the acute cerebral infarct. Clinically significant blood results from 1 April 2020 demonstrated a raised C-reactive protein (CRP) at 215 mg/L (normal 0–5 mg/L) and lymphopaenia at 0.5×10 9 (normal 1×10 9 to 3×10 9 ). Other routine blood results are provided in table 1 .

CT imaging of this patients’ brain demonstrating a wedge-shaped infarction of the anterior cerebral artery territory.

Chest X-ray demonstrating the bilateral COVID-19 pneumonia of this patient on admission.

Clinical biochemistry and haematology blood results of the patient

APTT, activated partial thromboplastin time; CRP, C-reactive protein; eGFR, estimated glomerular filtration rate; Hb, haemoglobin; INR, international normalised ratio; MCV, mean corpuscular volume; PT, prothrombin time; WCC, white cell count.

Interestingly the patient, in this case, was clinically assessed in the accident and emergency department on 23 March 2020, 9 days prior to admission, with symptoms of shortness of breath. His blood results from this day showed a CRP of 22 mg/L and a greater lymphopaenia at 0.3×10 9 . He had a chest X-ray ( figure 4 ), which indicated mild radiopacification in the left mid zone. He was initially treated with intravenous co-amoxiclav and ciprofloxacin. The following day he had minimal symptoms (CURB 65 score 1 for being over 65 years). Given improving blood results (declining CRP), he was discharged home with a course of oral amoxicillin and clarithromycin. As national governmental restrictions due to COVID-19 had not been formally announced until 23 March 2020, and inconsistencies regarding personal protective equipment training and usage existed during the earlier stages of this rapidly evolving pandemic, it is possible that this patient contracted COVID-19 within the local community, or during his prior hospital admission. It could be argued that the patient had early COVID-19 signs and symptoms, having presented with shortness of breath, lymphopaenia, and having had subtle infective chest X-ray changes. The patient explained he developed a stagnant productive cough, which began 5 days prior to his attendance to hospital on 23 March 2020. He responded to antibiotics, making a full recovery following 7 days of treatment. This information does not assimilate with the typical features of a COVID-19 infection. A diagnosis of community-acquired pneumonia or infective exacerbation of COPD seem more likely. However, given the high incidence of COVID-19 infections during this patients’ illness, an exposure and early COVID-19 illness, prior to the 23 March 2020, cannot be completely ruled out.

Chest X-ray conducted on prior admission illustrating mild radiopacification in the left mid zone.

On the current admission, this patient was managed with nasal cannula oxygen at 2 L. By the end of the day, this had progressed to a venturi mask, requiring 8 L of oxygen to maintain oxygen saturation. He had also become increasingly drowsy and confused, his GCS declined from 15 to 12. However, the patient was still haemodynamically stable, as he had been in the morning. An arterial blood gas demonstrated a respiratory alkalosis (pH 7.55, pCO 2 3.1, pO 2 6.7 and HCO 3 24.9, lactate 1.8, base excess 0.5). He was commenced on intravenous co-amoxiclav and ciprofloxacin, to treat a potential exacerbation of COPD. This patient had a COVID-19 throat swab on 1 April 2020. Before the result of this swab, an early discussion was held with the intensive care unit staff, who decided at 17:00 on 1 April 2020 that given the patients presentation, rapid deterioration, comorbidities and likely COVID-19 diagnosis he would not be for escalation to the intensive care unit, and if he were to deteriorate further the end of life pathway would be most appropriate. The discussion was reiterated to the patients’ family, who were in agreement with this. Although he had evidence of an ischaemic stroke on CT of his brain, it was agreed by all clinicians that intervention for this was not as much of a priority as providing optimal palliative care, therefore, a minimally invasive method of treatment was advocated by the stroke team. The patient was given 300 mg of aspirin and was not a candidate for fibrinolysis.

Outcome and follow-up

The following day, before the throat swab result, had appeared the patient deteriorated further, requiring 15 L of oxygen through a non-rebreather face mask at 60% FiO 2 to maintain his oxygen saturation, at a maximum of 88% overnight. At this point, he was unresponsive to voice, with a GCS of 5. Although, he was still haemodynamically stable, with a blood pressure of 126/74 mm Hg and a heart rate of 98 beats/min. His respiratory rate was 30 breaths/min. His worsening respiratory condition, combined with his declining level of consciousness made it impossible to clinically assess progression of the neurological deficit generated by his cerebral infarction. Moreover, the patient was declining sharply while receiving the maximal ward-based treatment available. The senior respiratory physician overseeing the patients’ care decided that a palliative approach was in this his best interest, which was agreed on by all parties. The respiratory team completed the ‘recognising dying’ documentation, which signified that priorities of care had shifted from curative treatment to palliative care. Although the palliative team was not formally involved in the care of the patient, the patient received comfort measures without further attempts at supporting oxygenation, or conduction of regular clinical observations. The COVID-19 throat swab confirmed a positive result on 2 April 2020. The patient was treated by the medical team under jurisdiction of the hospital palliative care team. This included the prescribing of anticipatory medications and a syringe driver, which was established on 3 April 2020. His antibiotic treatment, non-essential medication and intravenous fluid treatment were discontinued. His comatose condition persisted throughout the admission. Once the patients’ GCS was 5, it did not improve. The patient was pronounced dead by doctors at 08:40 on 5 April 2020.

SARS-CoV-2 is a type of coronavirus that was first reported to have caused pneumonia-like infection in humans on 3 December 2019. 5 As a group, coronaviruses are a common cause of upper and lower respiratory tract infections (especially in children) and have been researched extensively since they were first characterised in the 1960s. 6 To date, there are seven coronaviruses that are known to cause infection in humans, including SARS-CoV-1, the first known zoonotic coronavirus outbreak in November 2002. 7 Coronavirus infections pass through communities during the winter months, causing small outbreaks in local communities, that do not cause significant mortality or morbidity.

SARS-CoV-2 strain of coronavirus is classed as a zoonotic coronavirus, meaning the virus pathogen is transmitted from non-humans to cause disease in humans. However the rapid spread of SARS-CoV-2 indicates human to human transmission is present. From previous research on the transmission of coronaviruses and that of SARS-CoV-2 it can be inferred that SARS-CoV-2 spreads via respiratory droplets, either from direct inhalation, or indirectly touching surfaces with the virus and exposing the eyes, nose or mouth. 8 Common signs and symptoms of the COVID-19 infection identified in patients include high fevers, severe fatigue, dry cough, acute breathing difficulties, bilateral pneumonia on radiological imaging and lymphopaenia. 9 Most of these features were identified in this case study. The significance of COVID-19 is illustrated by the speed of its global spread and the potential to cause severe clinical presentations, which as of April 2020 can only be treated symptomatically. In Italy, as of mid-March 2020, it was reported that 12% of the entire COVID-19 positive population and 16% of all hospitalised patients had an admission to the intensive care unit. 10

The patient, in this case, illustrates the clinical relevance of understanding COVID-19, as he presented with an ischaemic stroke underlined by minimal respiratory symptoms, which progressed expeditiously, resulting in acute respiratory distress syndrome and subsequent death.

Our case is an example of a new and ever-evolving clinical correlation, between patients who present with a radiological confirmed ischaemic stroke and severe COVID-19 pneumonia. As of April 2020, no comprehensive data of the relationship between ischaemic stroke and COVID-19 has been published, however early retrospective case series from three hospitals in Wuhan, China have indicated that up to 36% of COVID-19 patients had neurological manifestations, including stroke. 11 These studies have not yet undergone peer review, but they tell us a great deal about the relationship between COVID-19 and ischaemic stroke, and have been used to influence the American Heart Associations ‘Temporary Emergency Guidance to US Stroke Centres During the COVID-19 Pandemic’. 12

The relationship between similar coronaviruses and other viruses, such as influenza in the development of ischaemic stroke has previously been researched and provide a basis for further investigation, into the prominence of COVID-19 and its relation to ischaemic stroke. 3 Studies of SARS-CoV-2 indicate its receptor-binding region for entry into the host cell is the same as ACE2, which is present on endothelial cells throughout the body. It may be the case that SARS-CoV-2 alters the conventional ability of ACE2 to protect endothelial function in blood vessels, promoting atherosclerotic plaque displacement by producing an inflammatory response, thus increasing the risk of ischaemic stroke development. 13

Other hypothesised reasons for stroke development in COVID-19 patients are the development of hypercoagulability, as a result of critical illness or new onset of arrhythmias, caused by severe infection. Some case studies in Wuhan described immense inflammatory responses to COVID-19, including elevated acute phase reactants, such as CRP and D-dimer. Raised D-dimers are a non-specific marker of a prothrombotic state and have been associated with greater morbidity and mortality relating to stroke and other neurological features. 14

Arrhythmias such as atrial fibrillation had been identified in 17% of 138 COVID-19 patients, in a study conducted in Wuhan, China. 15 In this report, the patient was known to have atrial fibrillation and was treated with rivaroxaban. The acute inflammatory state COVID-19 is known to produce had the potential to create a prothrombotic environment, culminating in an ischaemic stroke.

Some early case studies produced in Wuhan describe patients in the sixth decade of life that had not been previously noted to have antiphospholipid antibodies, contain the antibodies in blood results. They are antibodies signify antiphospholipid syndrome; a prothrombotic condition. 16 This raises the hypothesis concerning the ability of COVID-19 to evoke the creation of these antibodies and potentiate thrombotic events, such as ischaemic stroke.

No peer-reviewed studies on the effects of COVID-19 and mechanism of stroke are published as of April 2020; therefore, it is difficult to evidence a specific reason as to why COVID-19 patients are developing neurological signs. It is suspected that a mixture of the factors mentioned above influence the development of ischaemic stroke.

If we delve further into this patients’ comorbid state exclusive to COVID-19 infection, it can be argued that this patient was already at a relatively higher risk of stroke development compared with the general population. The fact this patient had previously had an ischaemic stroke illustrates a prior susceptibility. This patient had a known background of hypertension and atrial fibrillation, which as mentioned previously, can influence blood clot or plaque propagation in the development of an acute ischaemic event. 15 Although the patient was prescribed rivaroxaban as an anticoagulant, true consistent compliance to rivaroxaban or other medications such as amlodipine, clopidogrel, candesartan and atorvastatin cannot be confirmed; all of which can contribute to the reduction of influential factors in the development of ischaemic stroke. Furthermore, the fear of contracting COVID-19, in addition to his vague symptoms, unlike his prior ischaemic stroke, which demonstrated dense left-sided haemiparesis, led to a delay in presentation to hospital. This made treatment options like fibrinolysis unachievable, although it can be argued that if he was already infected with COVID-19, he would have still developed life-threatening COVID-19 pneumonia, regardless of whether he underwent fibrinolysis. It is therefore important to consider that if this patient did not contract COVID-19 pneumonia, he still had many risk factors that made him prone to ischaemic stroke formation. Thus, we must consider whether similar patients would suffer from ischaemic stroke, regardless of COVID-19 infection and whether COVID-19 impacts on the severity of the stroke as an entity.

Having said this, the management of these patients is dependent on the likelihood of a positive outcome from the COVID-19 infection. Establishing the ceiling of care is crucial, as it prevents incredibly unwell or unfit patients’ from going through futile treatments, ensuring respect and dignity in death, if this is the likely outcome. It also allows for the provision of limited or intensive resources, such as intensive care beds or endotracheal intubation during the COVID-19 pandemic, to those who are assessed by the multidisciplinary team to benefit the most from their use. The way to establish this ceiling of care is through an early multidisciplinary discussion. In this case, the patient did not convey his wishes regarding his care to the medical team or his family; therefore it was decided among intensive care specialists, respiratory physicians, stroke physicians and the patients’ relatives. The patient was discussed with the intensive care team, who decided that as the patient sustained two acute life-threatening illnesses simultaneously and had rapidly deteriorated, ward-based care with a view to palliate if the further deterioration was in the patients’ best interests. These decisions were not easy to make, especially as it was on the first day of presentation. This decision was made in the context of the patients’ comorbidities, including COPD, the patients’ age, and the availability of intensive care beds during the steep rise in intensive care admissions, in the midst of the COVID-19 pandemic ( figure 1 ). Furthermore, the patients’ rapid and permanent decline in GCS, entwined with the severe stroke on CT imaging of the brain made it more unlikely that significant and permanent recovery could be achieved from mechanical intubation, especially as the damage caused by the stroke could not be significantly reversed. As hospitals manage patients with COVID-19 in many parts of the world, there may be tension between the need to provide higher levels of care for an individual patient and the need to preserve finite resources to maximise the benefits for most patients. This patient presented during a steep rise in intensive care admissions, which may have influenced the early decision not to treat the patient in an intensive care setting. Retrospective studies from Wuhan investigating mortality in patients with multiple organ failure, in the setting of COVID-19, requiring intubation have demonstrated mortality can be up to 61.5%. 17 The mortality risk is even higher in those over 65 years of age with respiratory comorbidities, indicating why this patient was unlikely to survive an admission to the intensive care unit. 18

Regularly updating the patients’ family ensured cooperation, empathy and sympathy. The patients’ stroke was not seen as a priority given the severity of his COVID-19 pneumonia, therefore the least invasive, but most appropriate treatment was provided for his stroke. The British Association of Stroke Physicians advocate this approach and also request the notification to their organisation of COVID-19-related stroke cases, in the UK. 19

Learning points

• SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is one of seven known coronaviruses that commonly cause upper and lower respiratory tract infections. It is the cause of the 2019–2020 global coronavirus pandemic.
• The significance of COVID-19 is illustrated by the rapid speed of its spread globally and the potential to cause severe clinical presentations, such as ischaemic stroke.
• Early retrospective data has indicated that up to 36% of COVID-19 patients had neurological manifestations, including stroke.
• Potential mechanisms behind stroke in COVID-19 patients include a plethora of hypercoagulability secondary to critical illness and systemic inflammation, the development of arrhythmia, alteration to the vascular endothelium resulting in atherosclerotic plaque displacement and dehydration.
• It is vital that effective, open communication between the multidisciplinary team, patient and patients relatives is conducted early in order to firmly establish the most appropriate ceiling of care for the patient.

Contributors: SB was involved in the collecting of information for the case, the initial written draft of the case and researching existing data on acute stroke and COVID-19. He also edited drafts of the report. MH was involved in reviewing and editing drafts of the report and contributing new data. SP oversaw the conduction of the project and contributed addition research papers.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient consent for publication: Next of kin consent obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android . Learn more here!

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 7:  10 Real Cases on Transient Ischemic Attack and Stroke: Diagnosis, Management, and Follow-Up

Jeirym Miranda; Fareeha S. Alavi; Muhammad Saad

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

Case review, case discussion, clinical symptoms.

• Radiologic Findings
• Full Chapter
• Supplementary Content

Case 1: Management of Acute Thrombotic Cerebrovascular Accident Post Recombinant Tissue Plasminogen Activator Therapy

A 59-year-old Hispanic man presented with right upper and lower extremity weakness, associated with facial drop and slurred speech starting 2 hours before the presentation. He denied visual disturbance, headache, chest pain, palpitations, dyspnea, dysphagia, fever, dizziness, loss of consciousness, bowel or urinary incontinence, or trauma. His medical history was significant for uncontrolled type 2 diabetes mellitus, hypertension, hyperlipidemia, and benign prostatic hypertrophy. Social history included cigarette smoking (1 pack per day for 20 years) and alcohol intake of 3 to 4 beers daily. Family history was not significant, and he did not remember his medications. In the emergency department, his vital signs were stable. His physical examination was remarkable for right-sided facial droop, dysarthria, and right-sided hemiplegia. The rest of the examination findings were insignificant. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. The neurology team was consulted, and intravenous recombinant tissue plasminogen activator (t-PA) was administered along with high-intensity statin therapy. The patient was admitted to the intensive care unit where his hemodynamics were monitored for 24 hours and later transferred to the telemetry unit. MRI of the head revealed an acute 1.7-cm infarct of the left periventricular white matter and posterior left basal ganglia. How would you manage this case?

This case scenario presents a patient with acute ischemic cerebrovascular accident (CVA) requiring intravenous t-PA. Diagnosis was based on clinical neurologic symptoms and an NIHSS score of 7 and was later confirmed by neuroimaging. He had multiple comorbidities, including hypertension, diabetes, dyslipidemia, and smoking history, which put him at a higher risk for developing cardiovascular disease. Because his symptoms started within 4.5 hours of presentation, he was deemed to be a candidate for thrombolytics. The eligibility time line is estimated either by self-report or last witness of baseline status.

Ischemic strokes are caused by an obstruction of a blood vessel, which irrigates the brain mainly secondary to the development of atherosclerotic changes, leading to cerebral thrombosis and embolism. Diagnosis is made based on presenting symptoms and CT/MRI of the head, and the treatment is focused on cerebral reperfusion based on eligibility criteria and timing of presentation.

Symptoms include alteration of sensorium, numbness, decreased motor strength, facial drop, dysarthria, ataxia, visual disturbance, dizziness, and headache.

Sign in or create a free Access profile below to access even more exclusive content.

With an Access profile, you can save and manage favorites from your personal dashboard, complete case quizzes, review Q&A, and take these feature on the go with our Access app.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

What are you initial questions/concerns about this patient? What data do you want to focus on with your first head-to-toe assessment? What do you anticipate this patient needing based off this report? You fill out your report sheet, and it looks something like this:

You know you need more data, so you take a look through the chart. Namely, you want to see what his lab results are and want to check to see that the admitting MD ordered a lipid panel and HbA1c for this morning. No results yet, so it’s time to go see your patient…after all, he’s on q 30 min neuro checks until 10am. It’s going to be a busy morning!

Your initial assessment and AM rounds

0700: You head in to the room with the main goal of assessing Rick’s neurological status and BP. Because of his ETOH history, he’s at a higher risk for bleed than someone who doesn’t drink a case of beer a day. Speaking of this drinking habit…you want to confirm with the patient. If he really does drink that much, we’re going to have a problem in a day or two and we need to be prepared.

Your initial head-to-toe assessment reveals the following:

• NIHSS = 6…slowly improving!
• Pt is able to hold left arm up for 10 seconds with only slight drift noted…improvement! Pt states he can use urinal independently now. Yay!
• Facial droop is minor; speech only mildly slurred.
• VSS on nicardipine gtt. BP from the cuff is 150/74.
• Occasional PVCs on the monitor, but he’s holding his BP so you’re not too worried.
• Lungs clear, normoactive bowel sounds.
• Abrasion to right knee looks clean (thanks to the ED nurses!), open to air.
• No complaints of pain, no complaints of headache, blurred vision or worsening numbness in any extremity.
• Both IVs patent
• Pt confirms he does drink a case of beer a day.
• Pt states he is tired from being up all night, but understands need for frequent assessments. States he will try to sleep in between.

0715: You sit down to chart your initial assessment and look through the labs and orders. Your AM labs don’t show anything of surprise and you notice the lipid panel AND the HbA1c were ordered. That new resident is on top of her game!

0730: Back in to wake Rick and conduct a neuro assessment No changes. Whew! You get those SCDs on and help Rick brush his teeth. You didn’t finish your initial charting yet, so you do that now. You hope to get it done before your 0800 neuro check.

Your morning continues in this vein until 0900. You’ve been conducting neuro exams every 30 minutes and you’re happy to see that Rick’s NIHSS is now 3…he scores points for slight drift in left arm, left leg and slight slurred speech. Looks like he’s going to have a pretty impressive recovery.

During this time you also note that your AM labs are in:

• Na 140; K 3.2; Mg 1.6; Ca 8.2; Ph 1.1; Cr .90; BUN 12
• WBC 8.5; Hgb 9.5; Hct 37%; PLT 130; INR 1.2
• Total cholesterol: 260; HDL 26; LDL 210
• HbA1C: 12 (woah!)

0900: Time for morning meds! Because Rick is still NPO pending his swallow evaluation, you don’t have many meds to give…a protonix IV, keppra (prophylactic for seizure) and that’s about it! You know he’s going to do awesome on his swallow eval, so you call Speech Therapy to see when they might be by. If you can get him on some PO antihypertensives, you can get this nicardipine gtt off and stop taking his BP every 15 minutes (ouch!). Your 0900 neuro exam goes off without a hitch. You notice more frequent ectopy on the monitor and attribute it to his low K and Mag levels. Otherwise, Rick is doing awesome…and wouldn’t you know it, his wife is a lovely person who knows you are an RN who went to school for years and years and not a glorified waitress, so she never once asks you to bring her a cup of coffee. 😉

1000: Time for a blood sugar check. If this one is also elevated, you’re going to need to talk to the MD about coverage. And yes it is…240. All that stress must be causing an SNS response. Your last q 30 neuro check is stable and you let Rick know you’ll be spacing them out to hourly. He grunts in response and goes back to sleep. You let Jan, his wife, know to alert you immediately if he complains of any worsening stroke symptoms or a headache.

1010: Time for rounds! You update the medical team on Rick’s condition and ask for the following:

• A banana bag (an IV infusion of vitamins and thiamine that we give to ETOH patients)
• PO blood pressure meds (pending your swallow eval)
• A statin (his cholesterol is super high)
• Diabetic educator (based off his super high HbA1c)
• ETOH protocol (includes anti-anxiety meds and librium to help control DTs)
• K and Mag replacement
• BS coverage with an aggressive sliding scale

Just then, the speech therapist comes in to conduct an evaluation of Rick’s ability to swallow. She lets you know that he “did great” and will be on a chopped diet with thin liquids. This means his food will be cut up small, but he can have liquids that are NOT thickened…which is good, because thickened liquids are really weird. You make sure to ask her what she thinks of his ability to swallow pills and she states that he should do fine with average-sized pills…larger ones may need to be halved. Woohoo! Rick is making progress!

Before the MD leaves to hang out in the lounge, you alert her that the pt passed his swallow eval and has a recommendation from Speech Therapy. She puts in the orders for a carb-control, cardiac/reduced sodium diet and you are good to go!

1100: Another neuro exam…funny how those hours fly by, isn’t it? All is well in Rick’s world and he is performing components of the exam without even being asked. Is this cheating? 🙂 You hang his banana bag, give him his PO meds and check the compatibility of Mag with nicardipine. You decide not to run anything concurrent with this potent calcium channel blocker and realize you need to start another PIV (those banana bags are not compatible with ANYTHING and you want to get the Mag going now). You nail the IV on your first try and start the magnesium replacement. Your K replacement is ordered PO, so you want to get him a little lunch first so it doesn’t upset his stomach. Besides, when Mag is optimized, it makes it easier for the body to “hang on” to its potassium…so getting that Mag in there is a good idea!

1200: You check Rick’s blood sugar, see that it’s still high (232) and provide insulin coverage. You bring him his lunch tray AND a big ol’ potassium pill that you’ve kindly cut in half. You watch as he safely swallows the pill and you notice his BP is vastly improved. You cut the nicardipine gtt down to 2.5 and anticipate it being off within the hour. Good job, you! Rick’s neuro status is stable and you think his speech might be even more improved.

1245 : Jan comes rushing up to the nurse’s station saying, “He said he had a horrible headache and now I can’t get him to wakeup.” You hear a voice inside your head saying, “ooooooooohhhhh shoooooooooooot” Only you don’t say “shoot.” As you rush into his room questions run through your head:

• Did we overshoot his blood sugar control? Is this hypoglycemia?
• Did I turn the nicardipine down too much? Is he having a hypertensive bleed?
• Is he having a “hemorrhagic conversion” a common complication of stroke (especially after TPA)
• Is he able to protect his airway?
• How fast can we get to CT scan?

You grab a glucometer on your way in and ask one of your nurse pals to come in with you. You hand him the glucometer as you try to wake your pt. Your efforts are unsuccessful. You hear a gurgling in Rick’s throat and watch the monitor to see his O2 sat dropping to the mid 80s. We’ve got problems.

You immediately lower the head of the bed and ask your pal for the BVM (bag valve mask). You reposition the airway and notice slight improvement, but the sats still don’t climb above 90. You start bagging the patient and ask your nurse friend to call RT and the MD. Rick needs to be intubated STAT for airway protection and then you gotta go to CT.

As reinforcements enter the room,  you ask someone to finish the blood sugar (which never got done) and RT takes over bagging the pt. With manual ventilation, Rick’s sats come up to 98%, but he is still non-responsive. The blood sugar reads 140, so that’s not the problem. You run a BP and see it’s well within parameters.  Just then, the MD walks in as another RT shows up with the intubation try and a vent. Good teamwork, guys!

Doc Waters quickly assesses the situation, gets into place at the head of the bed and deftly intubates Rick as his wife cries in the corner. You notice your awesome charge nurse consoling her as she explains what is happening.

As CXR technician shows up to confirm endotracheal tube (ETT) placement. While they are setting up the machine, you quickly place an OGT tube so you can get confirmation of it at the same time as your ETT. They shoot the film and you then whisk Rick off to CT scan with your RT buddy at your side. Your heart sinks as you fear the worst has happened to your patient.

1315: CT scan shows Rick has now bled into his brain. It is one of the known risks of TPA and you are crushed that it has happened to your patient, especially one so young and who was doing so well. You let Doc Waters know of the results and page the neurologist on call as well.  When you speak to the neurologist, he tells you he’s consulted neurosurgery and ordered an MRI.

1400: You’ve spoken to the neurologist and received orders for tighter BP control (goal < 140) so you titrate the nicardipine gtt and also ask for an arterial line for closer monitoring. You get Rick settled after his emergent intubation, place a Foley catheter, update Jan and note that his neuro exam is awful…GCS is 3 (no eye opening, no verbal and decorticate posturing). The art line gets placed and MRI calls to tell you they’re ready for your patient. Off you go!

1530: You’re back from MRI and you call the neurosurgeon to let her know the results are available to view.

1545: Neurosurgeon calls you back to ask that you get an EVD kit ready for her. She’s on her way up to place a drain at the bedside. You look at the clock and realize you still have four more hours to go. It’s been a tough day. You find the cranial access kit (which includes a DRILL!) and get the EVD system set up.

1630: Your EVD is in place (thanks to a fast-acting neurosurgeon) and you notice that your intracranial pressure (ICP) is elevated. The neurosurgeon orders prophylactic Ancef (after all, she just performed a neurosurgical procedure!) mannitol q6 hours prn for elevated ICP as well as orders to keep the EVD at continuous drainage. Because you’ve recently reviewed the management of elevated ICP , you know that mannitol requires you to monitor your patient’s serum sodium and serum osmolality. You send a stat chemistry vial and do what you can to keep the ICP within parameters (decreased stimulation, positioning, sedation). With the sedation on board, you’re able to turn off your nicardipine gtt, but you want to keep a close eye and make sure that your CPP (cerebral perfusion pressure) is maintained above 70 (CPP = MAP – ICP). You may need levophed in order to keep CPP up while your patient is sedated. A stark contrast from how you started the day.

1700: You give your mannitol, clear your pumps and spend the next hour catching up on charting. You’re happy to see that the mannitol works quickly to reduce ICP and you make a mental note to keep an eye on urine output as you expect it to drastically increase due to the osmotic diuresis effect of this medication. You’ll want to keep a close eye on those electrolytes (especially K and Mag) Oh, speaking of K and Mag…did you remember to recheck those after you replaced them? You had a busy day and you had to prioritize…but better do that now, just to be safe! Chances are you can “add-on” the K and Mag test to the blood vial you sent earlier for the serum sodium. You spot Doc Waters and ask her to please review the x-ray for OGT placement so you can use it. She does and it’s fine…she writes an order to start Glucerna 1.2 at 20ml/hr.

1800:  Your hourly neuro exam shows no changes as your EVD continues to drain drain drain. You do your end-of-shift charting, ensure your IV bags are not going to run dry during your NOC shift buddy’s first hour, replace suction tubing, tidy up the room, get Rick repositioned and start the tube feeding. Though Rick didn’t fare well, you did everything you could, followed protocol and kept the team updated. You can be proud of the work you did today. 

Your report sheet, after everything that happened, now looks like this:

You are now ready to give an awesome end-of-shift report. Now go home and sleep!

____________________________________________________________

The information, including but not limited to, audio, video, text, and graphics contained on this website are for educational purposes only. No content on this website is intended to guide nursing practice and does not supersede any individual healthcare provider’s scope of practice or any nursing school curriculum. Additionally, no content on this website is intended to be a substitute for professional medical advice, diagnosis or treatment.

Want more resources to help you through nursing school? Grab the study guide right here !

Looking for a neuro study sheet? How about this one?

Want to review this on the run? Tune in to episode 135 of the Straight A Nursing podcast to study on the go!

20 Secrets of Successful Nursing Students

Being a successful nursing student is more than just study tips and test strategies. It’s a way of life.

you may also like...

Neurology Case Study: Episode 135

Trauma Case Study: Episode 31

Trauma Nursing Case Study

You cannot create a Lecturio account without granting permission to use your email address.

Congrats, you just activated your 24 hour free trial.

Enjoy your full access to all video lectures, quiz questions, articles and the board-style Qbank for the next 24 hours FOR FREE.

Neurology Case Study: Nursing Care of Stroke Patient

Course Overview: Medical Surgical Nursing and Pathophysiology

This case study is presented in high-quality videos that cover all the steps you need to know to take care of a stroke patient in the emergency department. The material is presented by our medical experts in an easy-to-understand way for the learner.

Course Details

• Duration 3:03 h
• Quiz questions 90
• Concept Pages 0
•  Videos
•  Concept Pages
• Review of Acute Stroke Treatment Goals – Stroke Nursing Care in ER 06:32 min Review of Acute Stroke Treatment Goals – Stroke Nursing Care in ER 3  quiz questions Review of Acute Stroke Treatment Goals – Stroke Nursing Care in ER 0 Concept Pages
• Case Introduction and FAST Screening – Stroke Nursing Care in ER 03:02 min Case Introduction and FAST Screening – Stroke Nursing Care in ER 2  quiz questions Case Introduction and FAST Screening – Stroke Nursing Care in ER 0 Concept Pages
• Immediate Nursing Priorities – Stroke Nursing Care in ER 06:31 min Immediate Nursing Priorities – Stroke Nursing Care in ER 3  quiz questions Immediate Nursing Priorities – Stroke Nursing Care in ER 0 Concept Pages
• Manifestations of Right- and Left-brain Stroke – Stroke Nursing Care in ER 05:25 min Manifestations of Right- and Left-brain Stroke – Stroke Nursing Care in ER 2  quiz questions Manifestations of Right- and Left-brain Stroke – Stroke Nursing Care in ER 0 Concept Pages
• Collaborating with HCP: SBAR Report – Stroke Nursing Care in ER 04:35 min Collaborating with HCP: SBAR Report – Stroke Nursing Care in ER 2  quiz questions Collaborating with HCP: SBAR Report – Stroke Nursing Care in ER 0 Concept Pages
• Collaborating with HCP: Initial Orders – Stroke Nursing Care in ER 04:34 min Collaborating with HCP: Initial Orders – Stroke Nursing Care in ER 3  quiz questions Collaborating with HCP: Initial Orders – Stroke Nursing Care in ER 0 Concept Pages
• NIH Stroke Scale (NIHSS) – Stroke Nursing Care in ER 02:51 min NIH Stroke Scale (NIHSS) – Stroke Nursing Care in ER 2  quiz questions NIH Stroke Scale (NIHSS) – Stroke Nursing Care in ER 0 Concept Pages
• Noncontrast CT – Stroke Nursing Care in ER 02:30 min Noncontrast CT – Stroke Nursing Care in ER 2  quiz questions Noncontrast CT – Stroke Nursing Care in ER 0 Concept Pages
• Patient and Family Consent – Stroke Nursing Care in ER 02:49 min Patient and Family Consent – Stroke Nursing Care in ER 2  quiz questions Patient and Family Consent – Stroke Nursing Care in ER 0 Concept Pages
• Thrombolytic Therapy (Alteplase) – Stroke Nursing Care in ER 08:03 min Thrombolytic Therapy (Alteplase) – Stroke Nursing Care in ER 4  quiz questions Thrombolytic Therapy (Alteplase) – Stroke Nursing Care in ER 0 Concept Pages
• Alteplase: Nursing Priorities and Dosage Calculation – Stroke Nursing Care in ER 08:15 min Alteplase: Nursing Priorities and Dosage Calculation – Stroke Nursing Care in ER 4  quiz questions Alteplase: Nursing Priorities and Dosage Calculation – Stroke Nursing Care in ER 0 Concept Pages
• Stroke Nursing Care in ER: In a Nutshell 01:24 min Stroke Nursing Care in ER: In a Nutshell 1  quiz question Stroke Nursing Care in ER: In a Nutshell 0 Concept Pages
• Review of Acute Stroke Treatment Goals – Stroke Nursing Care in ICU 03:48 min Review of Acute Stroke Treatment Goals – Stroke Nursing Care in ICU 2  quiz questions Review of Acute Stroke Treatment Goals – Stroke Nursing Care in ICU 0 Concept Pages
• Immediate Nursing Priorities– Stroke Nursing Care in ICU 04:54 min Immediate Nursing Priorities– Stroke Nursing Care in ICU 2  quiz questions Immediate Nursing Priorities– Stroke Nursing Care in ICU 0 Concept Pages
• 24 Hours after Alteplase: Nursing Priorities – Stroke Nursing Care in ICU 09:57 min 24 Hours after Alteplase: Nursing Priorities – Stroke Nursing Care in ICU 5  quiz questions 24 Hours after Alteplase: Nursing Priorities – Stroke Nursing Care in ICU 0 Concept Pages
• Blood Pressure Management – Stroke Nursing Care in ICU 07:32 min Blood Pressure Management – Stroke Nursing Care in ICU 4  quiz questions Blood Pressure Management – Stroke Nursing Care in ICU 0 Concept Pages
• 48+ Hours after Alteplase: SBAR Report – Stroke Nursing Care in ICU 04:01 min 48+ Hours after Alteplase: SBAR Report – Stroke Nursing Care in ICU 2  quiz questions 48+ Hours after Alteplase: SBAR Report – Stroke Nursing Care in ICU 0 Concept Pages
• Stroke Nursing Care in ICU: In a Nutshell 01:04 min Stroke Nursing Care in ICU: In a Nutshell 1  quiz question Stroke Nursing Care in ICU: In a Nutshell 0 Concept Pages
• Collaborating with HCP: Initial Orders – Stroke Nursing Care in Med-Surg 06:17 min Collaborating with HCP: Initial Orders – Stroke Nursing Care in Med-Surg 3  quiz questions Collaborating with HCP: Initial Orders – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Telemetry Unit: Acute Stroke Treatment Goals – Stroke Nursing Care in Med-Surg 04:15 min Telemetry Unit: Acute Stroke Treatment Goals – Stroke Nursing Care in Med-Surg 2  quiz questions Telemetry Unit: Acute Stroke Treatment Goals – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Immediate Nursing Priorities – Stroke Nursing Care in Med-Surg 05:10 min Immediate Nursing Priorities – Stroke Nursing Care in Med-Surg 2  quiz questions Immediate Nursing Priorities – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Neurological Interventions – Stroke Nursing Care in Med-Surg 10:38 min Neurological Interventions – Stroke Nursing Care in Med-Surg 5  quiz questions Neurological Interventions – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Homonymous Hemianopsia – Stroke Nursing Care in Med-Surg 07:16 min Homonymous Hemianopsia – Stroke Nursing Care in Med-Surg 4  quiz questions Homonymous Hemianopsia – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Right-Side Stroke – Stroke Nursing Care in Med-Surg 03:46 min Right-Side Stroke – Stroke Nursing Care in Med-Surg 2  quiz questions Right-Side Stroke – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Left-Side Stroke (Aphasia) – Stroke Nursing Care in Med-Surg 09:23 min Left-Side Stroke (Aphasia) – Stroke Nursing Care in Med-Surg 4  quiz questions Left-Side Stroke (Aphasia) – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Left-Side Stroke (Dysphasia and Dysarthria) – Stroke Nursing Care in Med-Surg 02:43 min Left-Side Stroke (Dysphasia and Dysarthria) – Stroke Nursing Care in Med-Surg 1  quiz question Left-Side Stroke (Dysphasia and Dysarthria) – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Emotions and Intellectual Function – Stroke Nursing Care in Med-Surg 03:37 min Emotions and Intellectual Function – Stroke Nursing Care in Med-Surg 2  quiz questions Emotions and Intellectual Function – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Cardiovascular Interventions: VTE – Stroke Nursing Care in Med-Surg 06:59 min Cardiovascular Interventions: VTE – Stroke Nursing Care in Med-Surg 3  quiz questions Cardiovascular Interventions: VTE – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Respiratory Interventions – Stroke Nursing Care in Med-Surg 04:05 min Respiratory Interventions – Stroke Nursing Care in Med-Surg 2  quiz questions Respiratory Interventions – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Gastrointestinal Interventions – Stroke Nursing Care in Med-Surg 05:47 min Gastrointestinal Interventions – Stroke Nursing Care in Med-Surg 3  quiz questions Gastrointestinal Interventions – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Renal/Urinary Interventions – Stroke Nursing Care in Med-Surg 04:22 min Renal/Urinary Interventions – Stroke Nursing Care in Med-Surg 2  quiz questions Renal/Urinary Interventions – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Skin – Stroke Nursing Care in Med-Surg 06:27 min Skin – Stroke Nursing Care in Med-Surg 3  quiz questions Skin – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Musculoskeletal/Mobility – Stroke Nursing Care in Med-Surg 04:59 min Musculoskeletal/Mobility – Stroke Nursing Care in Med-Surg 2  quiz questions Musculoskeletal/Mobility – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Ongoing Discharge Planning – Stroke Nursing Care in Med-Surg 04:25 min Ongoing Discharge Planning – Stroke Nursing Care in Med-Surg 2  quiz questions Ongoing Discharge Planning – Stroke Nursing Care in Med-Surg 0 Concept Pages
• Stroke Nursing Care in Med-Surg: In a Nutshell 05:54 min Stroke Nursing Care in Med-Surg: In a Nutshell 2  quiz questions Stroke Nursing Care in Med-Surg: In a Nutshell 0 Concept Pages

Your Educators of course Neurology Case Study: Nursing Care of Stroke Patient

Rhonda Lawes, PhD, RN

Dr. Rhonda Lawes is a Certified Nurse Educator (CNE), and an Assistant Professor at the University of Oklahoma College of Nursing in Oklahoma, USA. She obtained her PhD in Educational Psychology from Oklahoma State University in 2016. Due to her achievements, she has earned numerous teaching awards. She teaches nursing students how to use the science of cognitive learning to maximize their study effectiveness. Within Lecturio, Dr. Lawes is the Director of Nursing Education Programs, and teaches courses on Pharmacology (Nursing), Medical Surgical Nursing and Pathophysiology.

User reviews

I like the way the discussions are done. I don’t feel overwhelmed by medical terminologies.

Professor Lawes explains lesson very through, clearly and interesting. She exactly hits the important areas students need to learn and does that very smoothly

I so wish she did all the videos! Its so hard to watch the other presenters- i get lost in the information and don't understand as well :( Rhonda is so clear and gives appropriate examples along the way to aid in a much better absorption and understanding of the information.

I want to get certificate or diploma in nursing school diploma why you don’t have online free

See all 5 user reviews with text

I like it very much because it’s easy to recall. It’s perfect to refresh my brain, Thank you so much Ronda.

Get Premium to add bookmarks

Lecturio Premium gives you full access to all content and features.

• Medical Library
• Medical Schools
• General Business
• Development Initiative
• Website Owners

© 2024 Lecturio GmbH. All rights reserved.

• Data Privacy
• Terms and Conditions
• Legal Information

This presents an analysis of a case of Ischemic stroke in terms of possible etiology, pathophysiology, drug analysis and nursing care

New? Questions? Start Here!

• Information Hub
• Important Notices
• Need Access to Evidence
• Communities & Collections
• Publication Date
• Posting Date
• Subject(CINAHL)
• Item Format
• Level of Evidence
• Research Approach
• Sigma Chapters
• Author Affiliations
• Review Type

Ischemic stroke: A case study

View file(s).

Author Information

• Martinez, Rudolf Cymorr Kirby P. ;
• Sigma Affiliation

Item Information

Item link - use this link for citations and online mentions..

Clinical Focus: Adult Medical/Surgical

Repository Posting Date

Type information, category information, original publication info, conference information, rights holder.

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.

All permission requests should be directed accordingly and not to the Sigma Repository.

All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

14 Stroke (Cerebrovascular Accident) Nursing Care Plans

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 Problem Priorities

Nursing assessment, nursing diagnosis, nursing goals, 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, 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.

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.

Assess for the following subjective and objective data:

• See nursing assessment cues under Nursing Interventions and Actions.

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.

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:

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).

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).

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).

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).

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).

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).

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).

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).

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).

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). 

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).

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).

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).

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 nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

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 recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

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 edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other nursing care plans related to neurological disorders:

• Alzheimer’s Disease | 15 Care Plans
• Brain Tumor | 3 Care Plans
• Cerebral Palsy | 7 Care Plans
• Cerebrovascular Accident | 12 Care Plans
• Guillain-Barre Syndrome | 6 Care Plans
• Meningitis | 7 Care Plans
• Multiple Sclerosis | 9 Care Plans
• Parkinson’s Disease | 9 Care Plans
• Seizure Disorder | 4 Care Plans
• Spinal Cord Injury | 12 Care Plans
• Aali, G., Drummond, A., das Nair, R., & Shokraneh, F. (2020). Post-stroke fatigue: a scoping review. F1000 Research . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468563/
• Ablewhite, J., Nouri, F., Whisker, A., Thomas, S., Jones, F., das Nair, R., Condon, L., Jones, A., Sprigg, N., & Drummond, A. (2022). How do stroke survivors and their caregivers manage post-stroke fatigue? A qualitative study. Clinical Rehabilitation , 36 (10). https://journals.sagepub.com/doi/pdf/10.1177/02692155221107738
• Acharya, A. B., & Wroten, M. (2023, February 13). Broca Aphasia – StatPearls . NCBI. Retrieved May 17, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK436010/
• Acharya, A. B., & Wroten, M. B. (2022). Wernicke Aphasia – StatPearls . NCBI. Retrieved May 17, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK441951/
• AeYang, Y. (2019). The Effect of a Complex Intervention Program for Unilateral Neglect in Patients with Acute-Phase Stroke: A Randomized Controlled Trial . NCBI. Retrieved May 20, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816354/
• Alawieh, A., Zhao, J., & Feng, W. (2018). Factors affecting post-stroke motor recovery: Implications on neurotherapy after brain injury. Behavioral Brain Research , 340 . https://www.sciencedirect.com/science/article/abs/pii/S0166432816305411
• American Stroke Association. (2018). What is Aphasia? American Stroke Association. Retrieved May 17, 2023, from https://www.stroke.org/en/about-stroke/effects-of-stroke/cognitive-and-communication-effects-of-stroke/stroke-and-aphasia
• American Stroke Association. (2018, December 4). Visual Disturbances . American Stroke Association. Retrieved May 16, 2023, from https://www.stroke.org/en/about-stroke/effects-of-stroke/physical-effects-of-stroke/physical-impact/visual-disturbances
• American Stroke Association. (2023). Effects of Stroke . American Stroke Association. Retrieved May 22, 2023, from https://www.stroke.org/en/about-stroke/effects-of-stroke
• Aoyagi, M., Furuya, J., Matsubara, C., Yoshimi, K., Nakane, A., Nakagawa, K., Inaji, M., Sato, Y., Tohara, H., Minakuchi, S., & Maehara, T. (2021). Association between Improvement of Oral Health, Swallowing Function, and Nutritional Intake Method in Acute Stroke Patients. International Journal of Environmental Research and Public Health , 18 (21). https://www.mdpi.com/1660-4601/18/21/11379
• Aries, A. M., Pomeroy, V. M., Sim, J., Read, S., & Hunter, S. M. (2021). Sensory Stimulation of the Foot and Ankle Early Post-stroke: A Pilot and Feasibility Study. Frontiers in Neurology , 12 . https://www.frontiersin.org/articles/10.3389/fneur.2021.675106/full?&utm_source=Email_to_authors_&utm_medium=Email&utm_content=T1_11.5e1_author&utm_campaign=Email_publication&field=&journalName=Frontiers_in_Neurology&id=675106
• Blom-Smink, M. R.M.A., van de Sandt-Koenderman, M. W.M.E., Kruitwagen, C. L.J.J., El Hachioui, H., Visch-Brink, E. G., & Ribbers, G. M. (2017). Prediction of everyday verbal communicative ability of aphasic stroke patients after inpatient rehabilitation. Aphasiology , 31 (12). https://www.tandfonline.com/doi/abs/10.1080/02687038.2017.1296558
• Bright, F. A. S., & Reeves, B. (2022). Creating therapeutic relationship s through communication: a qualitative metasynthesis from the perspectives of people with communication impairment after stroke. Disability and Rehabilitation , 44 (12). https://www.tandfonline.com/doi/full/10.1080/09638288.2020.1849419
• Bruno, A., & Kishner, S. (2021, August 25). Motor Recovery In Stroke: Recovery Considerations, Theories of Recovery, Mechanisms of Recovery . Medscape Reference. Retrieved May 18, 2023, from https://emedicine.medscape.com/article/324386-overview#a1
• Cairer, M. (2022, December 13). Contractures After Stroke: How to Prevent & Reverse Them . Flint Rehab. Retrieved May 16, 2023, from https://www.flintrehab.com/contractures-after-stroke/
• Cairer, M. (2023, January 9). Sensory Reeducation After Stroke: How to Improve Sensation (Exercises & Methods) . Flint Rehab. Retrieved May 22, 2023, from https://www.flintrehab.com/sensory-reeducation-return-of-sensation-after-stroke/
• Camicia, M., Lutz, B., Summers, D., Klassman, L., & Vaughn, S. (2021). Nursing’s Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community. Stroke , 52 (12). https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.121.033938
• Canadian Stroke Best Practices. (2020). A clinical perspective on caring for heart/brain/mind patients . A clinical perspective on caring for heart/brain/mind patients. Retrieved May 21, 2023, from https://www.heartandstroke.ca/-/media/1-stroke-best-practices/tacls/tacls-transfers-april20b.ashx?rev=2f23a87a4f514104a00dcfeb39752b65
• Choi, H.-S., Shin, W.-S., & Bang, D.-H. (2019, May 3). Mirror Therapy Using Gesture Recognition for Upper Limb Function, Neck Discomfort, and Quality of Life After Chronic Stroke: A Single-Blind Randomized Controlled Trial . NCBI. Retrieved May 18, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511112/
• Denslow, E. (2020, September 9). Swollen Arm After Stroke: Why It Occurs & How to Treat It . Flint Rehab. Retrieved May 16, 2023, from https://www.flintrehab.com/swollen-arm-after-stroke/
• Denslow, E. (2023, February 9). Swallowing Exercises for Stroke Patients with Dysphagia . Flint Rehab. Retrieved May 19, 2023, from https://www.flintrehab.com/swallowing-exercises-for-stroke-patients/
• Fugazzaro, S., Denti, M., Accogli, M. A., Costi, S., Pagliacci, D., Calugi, S., Cavalli, E., Taricco, M., & Bardelli, R. (2020, May 22). Self-Management in Stroke Survivors: Development and Implementation of the Look after Yourself (LAY) Intervention . MDPI. Retrieved May 18, 2023, from https://www.mdpi.com/1660-4601/18/11/5925
• Hägglund, P., Hägg, M., Jäghagen, E. L., Larsson, B., & Wester, P. (2020, November 7). Oral neuromuscular training in patients with dysphagia after stroke: a prospective, randomized, open-label study with blinded evaluators – BMC Neurology . BMC Neurology. Retrieved May 19, 2023, from https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-020-01980-1
• Harrison, M., Ryan, T., Gardiner, C., & Jones, A. (2017). Psychological and emotional needs, assessment, and support post-stroke: a multi-perspective qualitative study. Topics in Stroke Rehabilitation , 24 (2). https://www.tandfonline.com/doi/abs/10.1080/10749357.2016.1196908
• Hinkle, J. L., Becker, K. J., Kim, J. S., Choi-Kwon, S., Saban, K. L., McNair, N., & Mead, G. E. (2017). Poststroke Fatigue: Emerging Evidence and Approaches to Management: A Scientific Statement for Healthcare Professionals From the American Heart Association. Stroke , 48 (7). https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000132
• Honado, A. S., Atigossou, O. L. G., Roy, J.-S., Daneault, J.-F., & Batcho, C. S. (2023). Relationships between Self-Efficacy and Post-Stroke Activity Limitations, Locomotor Ability, Physical Activity, and Community Reintegration in Sub-Saharan Africa: A Cross-Sectional Study . MDPI. Retrieved May 19, 2023, from https://www.mdpi.com/1660-4601/20/3/2286
• Huang, J. (2021). Dysarthria – Brain, Spinal Cord , and Nerve Disorders – MSD Manual Consumer Version . MSD Manuals. Retrieved May 17, 2023, from https://www.msdmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/brain-dysfunction/dysarthria
• Hughes, S. (2016, May 4). AHA/ASA Issues First-Ever Stroke Rehabilitation Guidelines . Medscape. Retrieved May 16, 2023, from https://www.medscape.com/viewarticle/862862
• Ikram, A. (2017). Deep Vein Thrombosis in Acute Stroke – A Systemic Review of the Literature . NCBI. Retrieved May 16, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825043/
• Jauch, E. C., & Lutsep, H. L. (2022, July 14). Ischemic Stroke: Practice Essentials, Background, Anatomy . Medscape Reference. Retrieved May 16, 2023, from https://emedicine.medscape.com/article/1916852-overview#a1
• Jauch, E. C., & Lutsep, H. L. (2022, December 31). Acute Management of Stroke: Initial Treatment, Thrombolytic Therapy, Stabilization of Airway and Breathing . Medscape Reference. Retrieved May 16, 2023, from https://emedicine.medscape.com/article/1159752-overview#a1
• Jones, C. A., Colletti, C. M., & Ding, M.-C. (2020, November 2). Post-stroke Dysphagia: Recent Insights and Unanswered Questions . NCBI. Retrieved May 19, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604228/
• Kirshner, H. S., & Chawla, J. (2023, April 17). Aphasia Treatment & Management: Medical Care, Consultations . Medscape Reference. Retrieved May 17, 2023, from https://emedicine.medscape.com/article/1135944-treatment#d8
• Lanctot, K. L., Lindsay, M. P., Smith, E. E., Sahlas, D. J., Foley, N., Gubitz, G., Austin, M., Ball, K., Bhogal, S., Blake, T., Hermann, N., Hogan, D., Khan, A., Longman, S., King, A., Leonard, C., Shoniker, T., Taylor, T., Teed, M., … Swartz, R. H. (2019). Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke. International Journal of Stroke , 15 (6). https://journals.sagepub.com/doi/full/10.1177/1747493019847334
• Li, J., Yuan, M., Liu, Y., Zhao, Y., Wang, J., & Guo, W. (2017). Incidence of constipation in stroke patients. Medicine (Baltimore) , 96 (25). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5484225/
• Li, J., Zhong, D., Ye, J., He, M., Liu, X., Zheng, H., Jin, R., & Zhang, S.-I. (2019). Rehabilitation for balance impairment in patients after stroke: a protocol of a systematic review and network meta-analysis. BMJ Open , 9 (7). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661695/
• Lo Buono, V., Corallo, F., Bramanti, P., & Marino, S. (2016). Coping strategies and health-related quality of life after stroke. Journal of Health Psychology , 22 (1). https://journals.sagepub.com/doi/abs/10.1177/1359105315595117?journalCode=hpqa
• Lou, S., Carstensen, K., Jorgensen, C. R., & Nielsen, C. P. (2017). Stroke patients’ and informal carers’ experiences with life after stroke: an overview of qualitative systematic reviews. Perspectives in Rehabilitation , 39 (3). https://www.tandfonline.com/doi/abs/10.3109/09638288.2016.1140836
• Marinho, V., Pinto, G. R., Bandeira, J., Oliveira, T., Carvalho, V., Rocha, K., Magalhäes, F., de Sousa, V. G., Bastos, V. H., Gupta, D., Orsini, M., & Teixeira, S. (2019). Impaired decision-making and time perception in individuals with stroke: Behavioral and neural correlates. Revue Neurologique (Paris) , 175 (6). https://pubmed.ncbi.nlm.nih.gov/30922589/
• McLeod, D. D., Beard, D. J., & Murtha, L. A. (2023). Intracranial Pressure Regulation in Stroke. Frontiers in Stroke . https://www.frontiersin.org/research-topics/46459/intracranial-pressure-regulation-in-stroke
• MinChun, S. (2021, December 31). Decreased Maximal Tongue Protrusion Length May Predict the Presence of Dysphagia in Stroke Patients . NCBI. Retrieved May 19, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8743842/
• Minshall, C., Pascoe, M. C., Thompson, D. R., Castle, D. J., McCabe, M., Chau, J. P.C., Jenkins, Z., Cameron, J., & Ski, C. F. (2019). Psychosocial interventions for stroke survivors, carers and survivor-carer dyads: a systematic review and meta-analysis. Topics in Stroke Rehabilitation , 26 (7). https://www.tandfonline.com/doi/abs/10.1080/10749357.2019.1625173
• Morone, G., Iosa, M., Paolucci, T., Muzzioli, L., & Paolucci, S. (2019). Relationship Between Body Mass Index and Rehabilitation Outcomes in Subacute Stroke With Dysphagia. American Journal of Physical Medicine & Rehabilitation , 98 (7). https://journals.lww.com/ajpmr/Abstract/2019/07000/Relationship_Between_Body_Mass_Index_and.9.aspx
• Munakomi, S. (2018). Ischemic Stroke – Abstract . Europe PMC. Retrieved May 16, 2023, from https://europepmc.org/article/NBK/nbk499997
• Oliveira-Kumakura, A. R. d. S., Machado Sousa, C. M. F., Biscaro, J. A., da Silva, K. C. R., Silva, J. L. G., Vasconcelos Morais, S. C. R., & de Oliveira Lopes, M. V. (2019). Clinical Validation of Nursing Diagnoses Related to Self-Care Deficits in Patients with Stroke. Clinical Nursing Research , 30 (4). https://journals.sagepub.com/doi/abs/10.1177/1054773819883352?journalCode=cnra
• O’ Rourke, B., Walsh, M. E., Brophy, R., Vallely, S., Murphy, N., Conroy, B., Cunningham, C., & Horgan, N. F. (2020, February 13). Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study – BMC Geriatrics . BMC Geriatrics. Retrieved May 21, 2023, from https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-1448-9
• Osawa, A., & Maeshima, S. (2021). Unilateral Spatial Neglect Due to Stroke – Stroke . NCBI. Retrieved May 20, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK572008/
• Pandian, J. D., Gall, S. L., Kate, M. P., Silva, G. S., Akinyemi, R. O., Ovbiagele, B. I., Lavados, P. M., Gandhi, D. B.C., & Thrift, A. G. (2018). Prevention of stroke: a global perspective. 392 , 10154 . https://www.sciencedirect.com/science/article/abs/pii/S0140673618312698
• Pandit, R. B., Matthews, M., & Sangle, S. (2017, February). Assessment of Neurological Deficit among Cerebrovascular Accident Patient in Selected Hospital. International Journal of Health Sciences and Research , 7 (2). https://d1wqtxts1xzle7.cloudfront.net/68473825/3._Neurological_Deficit_IJHSR-libre.pdf?1627876240=&response-content-disposition=inline%3B+filename%3DInternational_Journal_of_Health_Sciences.pdf&Expires=1684217385&Signature=aKCSXsZzbHNzCHkalbhHO6rB2v~btXpR4
• Park, S. J., Yang, H. K., Byun, S. J., Park, K. H., & Hwang, J.-M. (2018, October 15). Ocular motor cranial nerve palsy and increased risk of stroke in the general population . NCBI. Retrieved May 16, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188901/
• Physiopedia. (2022). Hemiplegic Shoulder Subluxation . Physiopedia. Retrieved May 17, 2023, from https://www.physio-pedia.com/Hemiplegic_Shoulder_Subluxation
• Physiopedia. (2023). Unilateral Neglect . Physiopedia. Retrieved May 20, 2023, from https://www.physio-pedia.com/Unilateral_Neglect
• Platz, T. (Ed.). (2021). Clinical Pathways in Stroke Rehabilitation: Evidence-based Clinical Practice Recommendations . Springer International Publishing.
• Plecash, A. R., Chebini, A., Ip, A., Lai, J. J., Mattar, A. A., Randhawa, J., & Field, T. S. (2019). Updates in the Treatment of Post-Stroke Pain. Current Neurology and Neuroscience Reports , 19 (86). https://link.springer.com/article/10.1007/s11910-019-1003-2
• Rayegani, S. M., Raeissadat, S. A., Alikhani, E., Bayat, M., Bahrami, M. H., & Karimzadeh, A. (2016). Evaluation of complete functional status of patients with stroke by Functional Independence Measure scale on admission, discharge, and six months poststroke. Iranian Journal of Neurology , 15 (4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5392193/
• Russo, M. J., Prodan, V., Meda, N., Carcavallo, L., Muracioli, A., Sabe, L., Bonamico, L., Allegri, R., & Olmos, L. (2017). High-technology Augmentative Communication for adults with post-stroke aphasia: a systematic review. Expert Review of Medical Devices , 14 (5). https://www.tandfonline.com/doi/abs/10.1080/17434440.2017.1324291
• Scuteri, D., Mantovani, E., Tamburin, S., Sandrini, G., Corasaniti, M. T., Bagetta, G., & Tonin, P. (2020). Opioids in Post-stroke Pain: A Systematic Review and Meta-Analysis. Frontiers in Pharmacology , 11 . https://www.frontiersin.org/articles/10.3389/fphar.2020.587050/full
• Suntrup-Krueger, S., Kemmling, A., Warnecke, T., Hamacher, C., Oelenberg, S., Niederstadt, T., Heindel, W., Wiendl, H., & Dziewas, R. (2017). The impact of lesion location on dysphagia incidence, pattern and complications in acute stroke. Part 2: Oropharyngeal residue, swallow and cough response, and pneumonia. 24 , 6 . https://onlinelibrary.wiley.com/doi/abs/10.1111/ene.13307
• Tadi, P., & Lui, F. (2023, February 28). Acute Stroke – StatPearls . NCBI. Retrieved May 16, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK535369/
• Tatmatsu-Rocha, J. C., Morais, P. A. F., Moraes Vitoriano, N. A., Silva Rodrigues, L. R., Simoes dos Santos, E. D., Tim, C. R., Oliveira, S. B., & Barros de Figueiredo, V. (2020). Medical devices for self-help management: the case of stroke rehabilitation. International Journal of Advanced Engineering Research and Science , 7 (5). http://journal-repository.theshillonga.com/index.php/ijaers/article/view/1994
• Villafañe, J. H., Taveggia, G., Galeri, S., Bissolotti, L., Mulle, C., Imperio, G., Valdes, K., Borboni, A., & Negrini, S. (2017). Efficacy of Short-Term Robot-Assisted Rehabilitation in Patients With Hand Paralysis After Stroke: A Randomized Clinical Trial. SAGE Journals , 13 (1). https://journals.sagepub.com/doi/abs/10.1177/1558944717692096?journalCode=hana
• The Wright Stuff, Inc. (2023). Bed Positioning Aids for Stroke Survivors . Caregiver Products. Retrieved May 16, 2023, from https://www.caregiverproducts.com/stroke-bed-positioning-aids.htmlYao, R., Yao, L., Rao, A., Ou, J., Wang, W., Hou, Q., Xu, C., & Gao, B.-L. (2022). Prevalence and risk factors of stroke-related sarcopenia at the subacute stage: A case control study. Frontiers in Neurology , 13 . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9393529/

22 thoughts on “14 Stroke (Cerebrovascular Accident) Nursing Care Plans”

there is a lot of good information but I don’t know how to cite the website and the author in the APA format

I agree with the comment above! How can we cite this awesome website?!

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_Communication

APA 6th Edition

Make sure to italicize: Nursing care plans: 8 cerebrovascular accident (stroke) nursing care plans.

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.

Very educational, learnt a lot how to provide care with a client who has had a CVA.

Great info! Very helpful.

very precise and informative. thank you.

Thank you :O had to be my last concept map ever for nursing school :)

Thanks so much for these topics,is highly refreshing.

Hi. Everything you have here is super helpful. But, I could figure out how to put this in in text citation. Can you help?

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/

Comment: the information was precise and helpful. thank you

Very informative

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

It’s very helpful .very informative.

Very helpful for nursing students like me.

I am so impressed by this plan , its quite teaching to nursing students.

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

Very articulate piece. It has guided writing my care plans

This site is very educational and informative! Great work done!

Nice visiting this site, it has helped me a lot in drawing good care plan. This source is reliable

Leave a Comment Cancel reply

NurseStudy.Net

Nursing Education Site

Cerebrovascular Accident CVA Stroke Nursing Diagnosis and Nursing Care Plan

Last updated on June 10th, 2023 at 07:44 pm

Cerebrovascular Accident CVA Stroke Nursing Care Plans Diagnosis and Interventions

Stroke NCLEX Review and Nursing Care Plans

Stroke is a medical emergency that occurs when a part of the brain’s blood supply is cut off causing oxygen deprivation and death to brain tissues. It is also known as cerebrovascular accident CVA.

Stroke can affect the brain’s functions and the effect depends on which part of the brain is affected.

Stroke can be categorized as hemorrhagic or ischemic depending on its cause.

Signs and Symptoms of Stroke

The clinical manifestations of stroke may occur suddenly. It is critical to seek immediate medical help as soon as possible to achieve a better outcome from treatment.   

• Difficulty speaking and understanding what others are saying – people having stroke may become confused and have slurred speech and have difficulty understanding other people’s words.
• Sudden paralysis of the face, arm, or leg – sudden onset of weakness, typically on one side of the body, is often noted in people having stroke.
• Problems with vision in one or both eyes – vision changes may occur when having stroke. The person may complain of sudden double vision or loss of vision.
• Headache – a person having stroke may complain of a sudden severe headache mostly accompanied by vomiting, dizziness, or confusion.
• Unsteady gait – weakness may affect the person’s coordination and alter the ability to walk.

Organizations and health institutions are recommending the use of the acronym “FAST” which refers to the following:

F – Face – a drop in one side of the face when the person smiles.

A – Arms – one arm will drop when both arms are raised at the same time.

S – Speech – slurred speech when asked to repeat a simple phrase.

T – Time – call for help when the above signs are observed.

Causes of Stroke

Like the other organs in the body, brain cells need oxygen to survive. Anything that can cause disruption to the blood supply in the brain can cause stroke.

The causes of stroke can be categorized as hemorrhagic or ischemic.

Hemorrhagic stroke – occurs when a blood vessel in the brain bursts allowing blood to seep through the brain which causes the surrounding brain cells to die. The following are the common causes of blood vessel rupture:

• High blood pressure
• Overuse of blood thinners or anticoagulants
• Trauma such as in a car accident
• Having protein deposits in the blood vessel wall such as in cases of cerebral amyloid angiopathy
• Ischemic stroke leading to hemorrhage

Ischemic stroke – occurs when a blood vessel is severely narrowed or occluded causing a significant reduction or total loss of blood supply in the brain.

This is the most common cause of stroke accounting to about 85% of cases reported.

The most common cause is a blood clot from elsewhere in the body that gets dislodged in one of the blood vessels in the brain.

One of the risks of having Atrial Fibrillation is that the condition can cause a stroke.

Another condition that may occur is transient ischemic attack (TIA) or “mini” stroke. It is a condition where the blood supply is cut off temporarily.

It only lasts for a few minutes to about 24 hours. It is often a warning sign to a full-blown stroke in the future hence prompt treatment is also necessary.

Complications of Stroke

• Paralysis. Paralysis on one side of the body is quite a common complication following stroke.
• Problem talking and swallowing. Stroke can affect the muscles responsible for talking and swallowing. Slurring of speech is often seen in people who had stroke.
• Memory loss and problems with logical thinking
• Emotional issues. Stroke can be challenging to some people and coping with it can affect their emotional state.
• Pain. Some people with stroke can develop pain from the loss of sensation on one side of the body.
•  Difficulty to carry out activities of daily living. Stroke can have lasting side effects that reduce the ability to carry out simple tasks.

Diagnosis of Stroke

• Blood tests – to measure the clotting ability, blood sugar level, and possible presence of infection.
• CT scan of the brain –helpful in the diagnosis of stroke. It will give detailed images of the brain that can show the presence of bleeding, ischemia, or tumor.
• MRI scan – another form of brain imaging that can be done if the CT scan is inconclusive or if a more detailed image of the brain is needed.
• Carotid scan – an ultrasound study of the carotid artery may be performed to observe for plaques in the arterial wall and assess the blood flow towards the brain.
• Echocardiogram – to look for possible blood clots in the heart that could cause ischemia to blood vessels in the brain.

Treatment of Stroke

Immediate medical attention is critical to prevent permanent disability.

For Ischemic Stroke:

• Administration of drugs to break up clots through intravenous injection – drugs that can dissolve clots will restore blood supply to the brain and prevent further damage. Giving the drugs intravenously allows for quicker delivery of drugs where it is needed.
• Administration of medications to break clots directly into the brain – medications can be administered directly into the brain through endovascular procedures. A catheter is inserted into the groin through an artery which will then thread to the brain.
• Removal of the blood clot through a stent retriever – a procedure to retrieve the clot can also be performed via stent insertion. A catheter is inserted to thread into the brain and then a stent is inserted in the tube to reach the part of the brain where the clot is.
• Carotid endarterectomy – this procedure involves the removal of plaque build-up in the carotid artery. This procedure carries risks especially in people with heart problems.
• Angioplasty and stents – the use of angioplasty balloons and stents can open a narrowed blood vessel.

For Hemorrhagic Stroke:

C ontrolling the bleeding is the focus of treatment in hemorrhagic stroke.

• Use of drugs to counteract the effects of blood thinning medications
• Blood transfusion – to thicken blood by improving blood volume
• Anti-hypertensives – drugs to lower blood pressure
• Surgical intervention – in cases of severe bleeding, surgical procedures to evacuate the blood and repair blood vessels may be required.
• Surgical clipping – this procedure involves the clipping of an aneurysm to prevent it from bursting or to control the bleeding if it has already ruptured.
• Endovascular embolization – a procedure that involves the use of coils to block the ruptured blood vessel.
• Surgical AVM removal – this procedure is only performed if the AVM is easily accessible in the brain.
• Stereotactic radiosurgery – this procedure involves the use of highly focused radiation to correct blood vessel malformations.

Stroke CVA Nursing Diagnosis

Nursing care plan for stroke 1.

Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral) related to cerebral edema and increased intracranial pressure (ICP) secondary to stroke as evidenced by drowsiness, confusion, headache, irritability, and memory problems

  Desired Outcome: The patient will re-establish effective cerebral tissue perfusion as evidenced by increased level of consciousness (i.e. awake and alert) and will show orientation with persons, places, and things.

Nursing Care Plan for Stroke 2

Nursing Diagnosis: Impaired physical mobility related to paralysis of one side of the body secondary to stroke as difficulty of movement, unsteady gait, generalized weakness, inability to do activities of daily living (ADLs) as normal, and verbalization of overwhelming tiredness/ fatigue

Desired Outcome: The patient will be able to perform activities of daily living within the limits of the present condition.

Nursing Care Plan for Stroke 3

Nursing Diagnosis: Self-Care Deficit related to physical limitations secondary to stroke as evidenced by inability to bathe, get dressed, and perform toileting activities as normal, and decreased level of strength and endurance

Desired Outcome: The patient will be able to demonstrate optimal performance of ADLs or activities of daily living.

Nursing Care Plan for Stroke 4

Risk for Unilateral Neglect

Nursing Diagnosis: Risk for Unilateral Neglect related to neurologic illness secondary to stroke

Desired Outcomes:

• The patient will exhibit and practice techniques that can be used to reduce unilateral neglect
• The patient will verbalize ways how to care for both sides of his/her body away from harm.
• The patient will demonstrate an optimized functioning level.
• The patient’s safety will be maintained and free from harm.
• The patient will adapt to physical disability.

Nursing Care Plan for Stroke 5

Risk for Disuse Syndrome

Nursing Diagnosis: Risk for Disuse Syndrome related to physical immobilization secondary to stroke

• The patient will express understanding of the methods to decrease immobilization.
• The patient’s relatives will demonstrate methods to help the patient to ambulate and do a diversional activity.
• The patient will express comfort after the rehabilitation interventions.
• The patient’s relative will demonstrate proper transfer techniques.

Nursing Care Plan for Stroke 6

Nursing Diagnosis: Acute Pain related to hemiplegia secondary to stroke as evidenced by the patient’s verbalization of shoulder stiffness, immobility, spasticity, and contractures.

• The patient expresses that the pain scale lessen.
• The patient will show understanding regarding recovery and rehabilitation techniques.
• The patient will verbalize the absence of side effects from the pain medications.
• The patient will show understanding of the diversional activities and relaxation skills.

More Nursing Diagnosis for Stroke CVA

• Impaired Verbal Communication
• Disturbed Sensory Perception
• Risk for Impaired Swallowing
• Risk for Injury / Fall

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Leave a Comment Cancel reply

This site uses Akismet to reduce spam. Learn how your comment data is processed .

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Stroke case study

• Sanaya Batcho
• Kara Kitzmiller
• Emma Overman

Our reason for choosing this disorder

Stroke is the leading cause of disability in the United States. As advanced practice nurses, we anticipate caring for those impacted by strokes in many healthcare settings including emergency rooms, acute care, rehab settings, extended care facilities, and in primary care. Early diagnosis and treatment are imperative in the treatment of a stroke in order to minimize permanent deficits so it is important for advanced practice nurses to be proficient in recognizing clinical manifestations of a stroke. There are also many modifiable risk factors for strokes so advanced practice nurses need to be able to educate patients and families on potential lifestyle changes that can decrease stroke risk.

• Open access
• Published: 15 May 2024

Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke

• Helena Teede 1 , 2   na1 ,
• Dominique A. Cadilhac 3 , 4   na1 ,
• Tara Purvis 3 ,
• Monique F. Kilkenny 3 , 4 ,
• Bruce C.V. Campbell 4 , 5 , 6 ,
• Coralie English 7 ,
• Alison Johnson 2 ,
• Emily Callander 1 ,
• Rohan S. Grimley 8 , 9 ,
• Christopher Levi 10 ,
• Sandy Middleton 11 , 12 ,
• Kelvin Hill 13 &
• Joanne Enticott   ORCID: orcid.org/0000-0002-4480-5690 1  

BMC Medicine volume  22 , Article number:  198 ( 2024 ) Cite this article

1 Altmetric

Metrics details

In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit.

Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement.

Conclusions

The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.

Peer Review reports

Internationally, health systems are facing a crisis, driven by an ageing population, increasing complexity, multi-morbidity, rapidly advancing health technology and rising costs that threaten sustainability and mandate transformation and improvement [ 1 , 2 ]. Although research has generated solutions to healthcare challenges, and the advent of big data and digital health holds great promise, entrenched siloes and poor integration of knowledge generation, knowledge implementation and healthcare delivery between stakeholders, curtails momentum towards, and consistent attainment of, evidence-and value-based care [ 3 ]. This is compounded by the short supply of research and innovation leadership within the healthcare sector, and poorly integrated and often inaccessible health data systems, which have crippled the potential to deliver on digital-driven innovation [ 4 ]. Current approaches to healthcare improvement are also often isolated with limited sustainability, scale-up and impact [ 5 ].

Evidence suggests that integration and partnership across academic and healthcare delivery stakeholders are key to progress, including those with lived experience and their families (referred to here as consumers and community), diverse disciplines (both research and clinical), policy makers and funders. Utilization of evidence from research and evidence from practice including data from routine care, supported by implementation research, are key to sustainably embedding improvement and optimising health care and outcomes. A strategy to achieve this integration is through the Learning Health System (LHS) (Fig.  1 ) [ 2 , 6 , 7 , 8 ]. Although there are numerous publications on LHS approaches [ 9 , 10 , 11 , 12 ], many focus on research perspectives and data, most do not demonstrate tangible healthcare improvement or better health outcomes. [ 6 ]

Monash Learning Health System: The Learn Together for Better Health Framework developed by Monash Partners and Monash University (from Enticott et al. 2021 [ 7 ]). Four evidence quadrants: Q1 (orange) is evidence from stakeholders; Q2 (green) is evidence from research; Q3 (light blue) is evidence from data; and, Q4 (dark blue) is evidence from implementation and healthcare improvement

In developed nations, it has been estimated that 60% of care provided aligns with the evidence base, 30% is low value and 10% is potentially harmful [ 13 ]. In some areas, clinical advances have been rapid and research and evidence have paved the way for dramatic improvement in outcomes, mandating rapid implementation of evidence into healthcare (e.g. polio and COVID-19 vaccines). However, healthcare improvement is challenging and slow [ 5 ]. Health systems are highly complex in their design, networks and interacting components, and change is difficult to enact, sustain and scale up. [ 3 ] New effective strategies are needed to meet community needs and deliver evidence-based and value-based care, which reorients care from serving the provider, services and system, towards serving community needs, based on evidence and quality. It goes beyond cost to encompass patient and provider experience, quality care and outcomes, efficiency and sustainability [ 2 , 6 ].

The costs of stroke care are expected to rise rapidly in the next decades, unless improvements in stroke care to reduce the disabling effects of strokes can be successfully developed and implemented [ 14 ]. Here, we briefly describe the Monash LHS framework (Fig.  1 ) [ 2 , 6 , 7 ] and outline an exemplar case in order to demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare. The Australian LHS exemplar in stroke care has driven nationwide improvement in stroke care since 2007.

An evidence-based Learning Health System framework

In Australia, members of this author group (HT, AJ, JE) have rigorously co-developed an evidence-based LHS framework, known simply as the Monash LHS [ 7 ]. The Monash LHS was designed to support sustainable, iterative and continuous robust benefit of improved clinical outcomes. It was created with national engagement in order to be applicable to Australian settings. Through this rigorous approach, core LHS principles and components have been established (Fig.  1 ). Evidence shows that people/workforce, culture, standards, governance and resources were all key to an effective LHS [ 2 , 6 ]. Culture is vital including trust, transparency, partnership and co-design. Key processes include legally compliant data sharing, linkage and governance, resources, and infrastructure [ 4 ]. The Monash LHS integrates disparate and often siloed stakeholders, infrastructure and expertise to ‘Learn Together for Better Health’ [ 7 ] (Fig.  1 ). This integrates (i) evidence from community and stakeholders including priority areas and outcomes; (ii) evidence from research and guidelines; (iii) evidence from practice (from data) with advanced analytics and benchmarking; and (iv) evidence from implementation science and health economics. Importantly, it starts with the problem and priorities of key stakeholders including the community, health professionals and services and creates an iterative learning system to address these. The following case study was chosen as it is an exemplar of how a Monash LHS-aligned national stroke program has delivered clinical benefit.

Australian Stroke Learning Health System

Internationally, the application of LHS approaches in stroke has resulted in improved stroke care and outcomes [ 12 ]. For example, in Canada a sustained decrease in 30-day in-hospital mortality has been found commensurate with an increase in resources to establish the multifactorial stroke system intervention for stroke treatment and prevention [ 15 ]. Arguably, with rapid advances in evidence and in the context of an ageing population with high cost and care burden and substantive impacts on quality of life, stroke is an area with a need for rapid research translation into evidence-based and value-based healthcare improvement. However, a recent systematic review found that the existing literature had few comprehensive examples of LHS adoption [ 12 ]. Although healthcare improvement systems and approaches were described, less is known about patient-clinician and stakeholder engagement, governance and culture, or embedding of data informatics into everyday practice to inform and drive improvement [ 12 ]. For example, in a recent review of quality improvement collaborations, it was found that although clinical processes in stroke care are improved, their short-term nature means there is uncertainty about sustainability and impacts on patient outcomes [ 16 ]. Table  1 provides the main features of the Australian Stroke LHS based on the four core domains and eight elements of the Learning Together for Better Health Framework described in Fig.  1 . The features are further expanded on in the following sections.

Evidence from stakeholders (LHS quadrant 1, Fig.  1 )

Engagement, partners and priorities.

Within the stroke field, there have been various support mechanisms to facilitate an LHS approach including partnership and broad stakeholder engagement that includes clinical networks and policy makers from different jurisdictions. Since 2008, the Australian Stroke Coalition has been co-led by the Stroke Foundation, a charitable consumer advocacy organisation, and Stroke Society of Australasia a professional society with membership covering academics and multidisciplinary clinician networks, that are collectively working to improve stroke care ( https://australianstrokecoalition.org.au/ ). Surveys, focus groups and workshops have been used for identifying priorities from stakeholders. Recent agreed priorities have been to improve stroke care and strengthen the voice for stroke care at a national ( https://strokefoundation.org.au/ ) and international level ( https://www.world-stroke.org/news-and-blog/news/world-stroke-organization-tackle-gaps-in-access-to-quality-stroke-care ), as well as reduce duplication amongst stakeholders. This activity is built on a foundation and culture of research and innovation embedded within the stroke ‘community of practice’. Consumers, as people with lived experience of stroke are important members of the Australian Stroke Coalition, as well as representatives from different clinical colleges. Consumers also provide critical input to a range of LHS activities via the Stroke Foundation Consumer Council, Stroke Living Guidelines committees, and the Australian Stroke Clinical Registry (AuSCR) Steering Committee (described below).

Evidence from research (LHS quadrant 2, Fig.  1 )

Advancement of the evidence for stroke interventions and synthesis into clinical guidelines.

To implement best practice, it is crucial to distil the large volume of scientific and trial literature into actionable recommendations for clinicians to use in practice [ 24 ]. The first Australian clinical guidelines for acute stroke were produced in 2003 following the increasing evidence emerging for prevention interventions (e.g. carotid endarterectomy, blood pressure lowering), acute medical treatments (intravenous thrombolysis, aspirin within 48 h of ischemic stroke), and optimised hospital management (care in dedicated stroke units by a specialised and coordinated multidisciplinary team) [ 25 ]. Importantly, a number of the innovations were developed, researched and proven effective by key opinion leaders embedded in the Australian stroke care community. In 2005, the clinical guidelines for Stroke Rehabilitation and Recovery [ 26 ] were produced, with subsequent merged guidelines periodically updated. However, the traditional process of periodic guideline updates is challenging for end users when new research can render recommendations redundant and this lack of currency erodes stakeholder trust [ 27 ]. In response to this challenge the Stroke Foundation and Cochrane Australia entered a pioneering project to produce the first electronic ‘living’ guidelines globally [ 20 ]. Major shifts in the evidence for reperfusion therapies (e.g. extended time-window intravenous thrombolysis and endovascular clot retrieval), among other advances, were able to be converted into new recommendations, approved by the Australian National Health and Medical Research Council within a few months of publication. Feedback on this process confirmed the increased use and trust in the guidelines by clinicians. The process informed other living guidelines programs, including the successful COVID-19 clinical guidelines [ 28 ].

However, best practice clinical guideline recommendations are necessary but insufficient for healthcare improvement and nesting these within an LHS with stakeholder partnership, enables implementation via a range of proven methods, including audit and feedback strategies [ 29 ].

Evidence from data and practice (LHS quadrant 3, Fig.  1 )

Data systems and benchmarking : revealing the disparities in care between health services. A national system for standardized stroke data collection was established as the National Stroke Audit program in 2007 by the Stroke Foundation [ 30 ] following various state-level programs (e.g. New South Wales Audit) [ 31 ] to identify evidence-practice gaps and prioritise improvement efforts to increase access to stroke units and other acute treatments [ 32 ]. The Audit program alternates each year between acute (commencing in 2007) and rehabilitation in-patient services (commencing in 2008). The Audit program provides a ‘deep dive’ on the majority of recommendations in the clinical guidelines whereby participating hospitals provide audits of up to 40 consecutive patient medical records and respond to a survey about organizational resources to manage stroke. In 2009, the AuSCR was established to provide information on patients managed in acute hospitals based on a small subset of quality processes of care linked to benchmarked reports of performance (Fig.  2 ) [ 33 ]. In this way, the continuous collection of high-priority processes of stroke care could be regularly collected and reviewed to guide improvement to care [ 34 ]. Plus clinical quality registry programs within Australia have shown a meaningful return on investment attributed to enhanced survival, improvements in quality of life and avoided costs of treatment or hospital stay [ 35 ].

Example performance report from the Australian Stroke Clinical Registry: average door-to-needle time in providing intravenous thrombolysis by different hospitals in 2021 [ 36 ]. Each bar in the figure represents a single hospital

The Australian Stroke Coalition endorsed the creation of an integrated technological solution for collecting data through a single portal for multiple programs in 2013. In 2015, the Stroke Foundation, AuSCR consortium, and other relevant groups cooperated to design an integrated data management platform (the Australian Stroke Data Tool) to reduce duplication of effort for hospital staff in the collection of overlapping variables in the same patients [ 19 ]. Importantly, a national data dictionary then provided the common data definitions to facilitate standardized data capture. Another important feature of AuSCR is the collection of patient-reported outcome surveys between 90 and 180 days after stroke, and annual linkage with national death records to ascertain survival status [ 33 ]. To support a LHS approach, hospitals that participate in AuSCR have access to a range of real-time performance reports. In efforts to minimize the burden of data collection in the AuSCR, interoperability approaches to import data directly from hospital or state-level managed stroke databases have been established (Fig.  3 ); however, the application has been variable and 41% of hospitals still manually enter all their data.

Current status of automated data importing solutions in the Australian Stroke Clinical Registry, 2022, with ‘ n ’ representing the number of hospitals. AuSCR, Australian Stroke Clinical Registry; AuSDaT, Australian Stroke Data Tool; API, Application Programming Interface; ICD, International Classification of Diseases; RedCAP, Research Electronic Data Capture; eMR, electronic medical records

For acute stroke care, the Australian Commission on Quality and Safety in Health Care facilitated the co-design (clinicians, academics, consumers) and publication of the national Acute Stroke Clinical Care Standard in 2015 [ 17 ], and subsequent review [ 18 ]. The indicator set for the Acute Stroke Standard then informed the expansion of the minimum dataset for AuSCR so that hospitals could routinely track their performance. The national Audit program enabled hospitals not involved in the AuSCR to assess their performance every two years against the Acute Stroke Standard. Complementing these efforts, the Stroke Foundation, working with the sector, developed the Acute and Rehabilitation Stroke Services Frameworks to outline the principles, essential elements, models of care and staffing recommendations for stroke services ( https://informme.org.au/guidelines/national-stroke-services-frameworks ). The Frameworks are intended to guide where stroke services should be developed, and monitor their uptake with the organizational survey component of the Audit program.

Evidence from implementation and healthcare improvement (LHS quadrant 4, Fig.  1 )

Research to better utilize and augment data from registries through linkage [ 37 , 38 , 39 , 40 ] and to ensure presentation of hospital or service level data are understood by clinicians has ensured advancement in the field for the Australian Stroke LHS [ 41 ]. Importantly, greater insights into whole patient journeys, before and after a stroke, can now enable exploration of value-based care. The LHS and stroke data platform have enabled focused and time-limited projects to create a better understanding of the quality of care in acute or rehabilitation settings [ 22 , 42 , 43 ]. Within stroke, all the elements of an LHS culminate into the ready availability of benchmarked performance data and support for implementation of strategies to address gaps in care.

Implementation research to grow the evidence base for effective improvement interventions has also been a key pillar in the Australian context. These include multi-component implementation interventions to achieve behaviour change for particular aspects of stroke care, [ 22 , 23 , 44 , 45 ] and real-world approaches to augmenting access to hyperacute interventions in stroke through the use of technology and telehealth [ 46 , 47 , 48 , 49 ]. The evidence from these studies feeds into the living guidelines program and the data collection systems, such as the Audit program or AuSCR, which are then amended to ensure data aligns to recommended care. For example, the use of ‘hyperacute aspirin within the first 48 h of ischemic stroke’ was modified to be ‘hyperacute antiplatelet…’ to incorporate new evidence that other medications or combinations are appropriate to use. Additionally, new datasets have been developed to align with evidence such as the Fever, Sugar, and Swallow variables [ 42 ]. Evidence on improvements in access to best practice care from the acute Audit program [ 50 ] and AuSCR is emerging [ 36 ]. For example, between 2007 and 2017, the odds of receiving intravenous thrombolysis after ischemic stroke increased by 16% 9OR 1.06 95% CI 1.13–1.18) and being managed in a stroke unit by 18% (OR 1.18 95% CI 1.17–1.20). Over this period, the median length of hospital stay for all patients decreased from 6.3 days in 2007 to 5.0 days in 2017 [ 51 ]. When considering the number of additional patients who would receive treatment in 2017 in comparison to 2007 it was estimated that without this additional treatment, over 17,000 healthy years of life would be lost in 2017 (17,786 disability-adjusted life years) [ 51 ]. There is evidence on the cost-effectiveness of different system-focussed strategies to augment treatment access for acute ischemic stroke (e.g. Victorian Stroke Telemedicine program [ 52 ] and Melbourne Mobile Stroke Unit ambulance [ 53 ]). Reciprocally, evidence from the national Rehabilitation Audit, where the LHS approach has been less complete or embedded, has shown fewer areas of healthcare improvement over time [ 51 , 54 ].

Within the field of stroke in Australia, there is indirect evidence that the collective efforts that align to establishing the components of a LHS have had an impact. Overall, the age-standardised rate of stroke events has reduced by 27% between 2001 and 2020, from 169 to 124 events per 100,000 population. Substantial declines in mortality rates have been reported since 1980. Commensurate with national clinical guidelines being updated in 2007 and the first National Stroke Audit being undertaken in 2007, the mortality rates for men (37.4 deaths per 100,000) and women (36.1 deaths per 100,0000 has declined to 23.8 and 23.9 per 100,000, respectively in 2021 [ 55 ].

Underpinning the LHS with the integration of the four quadrants of evidence from stakeholders, research and guidelines, practice and implementation, and core LHS principles have been addressed. Leadership and governance have been important, and programs have been established to augment workforce training and capacity building in best practice professional development. Medical practitioners are able to undertake courses and mentoring through the Australasian Stroke Academy ( http://www.strokeacademy.com.au/ ) while nurses (and other health professionals) can access teaching modules in stroke care from the Acute Stroke Nurses Education Network ( https://asnen.org/ ). The Association of Neurovascular Clinicians offers distance-accessible education and certification to develop stroke expertise for interdisciplinary professionals, including advanced stroke co-ordinator certification ( www.anvc.org ). Consumer initiative interventions are also used in the design of the AuSCR Public Summary Annual reports (available at https://auscr.com.au/about/annual-reports/ ) and consumer-related resources related to the Living Guidelines ( https://enableme.org.au/resources ).

The important success factors and lessons from stroke as a national exemplar LHS in Australia include leadership, culture, workforce and resources integrated with (1) established and broad partnerships across the academic-clinical sector divide and stakeholder engagement; (2) the living guidelines program; (3) national data infrastructure, including a national data dictionary that provides the common data framework to support standardized data capture; (4) various implementation strategies including benchmarking and feedback as well as engagement strategies targeting different levels of the health system; and (5) implementation and improvement research to advance stroke systems of care and reduce unwarranted variation in practice (Fig.  1 ). Priority opportunities now include the advancement of interoperability with electronic medical records as an area all clinical quality registry’s programs needs to be addressed, as well as providing more dynamic and interactive data dashboards tailored to the need of clinicians and health service executives.

There is a clear mandate to optimise healthcare improvement with big data offering major opportunities for change. However, we have lacked the approaches to capture evidence from the community and stakeholders, to integrate evidence from research, to capture and leverage data or evidence from practice and to generate and build on evidence from implementation using iterative system-level improvement. The LHS provides this opportunity and is shown to deliver impact. Here, we have outlined the process applied to generate an evidence-based LHS and provide a leading exemplar in stroke care. This highlights the value of moving from single-focus isolated approaches/initiatives to healthcare improvement and the benefit of integration to deliver demonstrable outcomes for our funders and key stakeholders — our community. This work provides insight into strategies that can both apply evidence-based processes to healthcare improvement as well as implementing evidence-based practices into care, moving beyond research as an endpoint, to research as an enabler, underpinning delivery of better healthcare.

Availability of data and materials

Not applicable

Abbreviations

Australian Stroke Clinical Registry

Confidence interval

• Learning Health System

World Health Organization. Delivering quality health services . OECD Publishing; 2018.

Enticott J, Braaf S, Johnson A, Jones A, Teede HJ. Leaders’ perspectives on learning health systems: A qualitative study. BMC Health Serv Res. 2020;20:1087.

Article   PubMed   PubMed Central   Google Scholar  

Melder A, Robinson T, McLoughlin I, Iedema R, Teede H. An overview of healthcare improvement: Unpacking the complexity for clinicians and managers in a learning health system. Intern Med J. 2020;50:1174–84.

Article   PubMed   Google Scholar  

Alberto IRI, Alberto NRI, Ghosh AK, Jain B, Jayakumar S, Martinez-Martin N, et al. The impact of commercial health datasets on medical research and health-care algorithms. Lancet Digit Health. 2023;5:e288–94.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Dixon-Woods M. How to improve healthcare improvement—an essay by Mary Dixon-Woods. BMJ. 2019;367: l5514.

Enticott J, Johnson A, Teede H. Learning health systems using data to drive healthcare improvement and impact: A systematic review. BMC Health Serv Res. 2021;21:200.

Enticott JC, Melder A, Johnson A, Jones A, Shaw T, Keech W, et al. A learning health system framework to operationalize health data to improve quality care: An Australian perspective. Front Med (Lausanne). 2021;8:730021.

Dammery G, Ellis LA, Churruca K, Mahadeva J, Lopez F, Carrigan A, et al. The journey to a learning health system in primary care: A qualitative case study utilising an embedded research approach. BMC Prim Care. 2023;24:22.

Foley T, Horwitz L, Zahran R. The learning healthcare project: Realising the potential of learning health systems. 2021. Available from https://learninghealthcareproject.org/wp-content/uploads/2021/05/LHS2021report.pdf . Accessed Jan 2024.

Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Washington: The National Academies Press; 2013.

Google Scholar  

Zurynski Y, Smith CL, Vedovi A, Ellis LA, Knaggs G, Meulenbroeks I, et al. Mapping the learning health system: A scoping review of current evidence - a white paper. 2020:63

Cadilhac DA, Bravata DM, Bettger J, Mikulik R, Norrving B, Uvere E, et al. Stroke learning health systems: A topical narrative review with case examples. Stroke. 2023;54:1148–59.

Braithwaite J, Glasziou P, Westbrook J. The three numbers you need to know about healthcare: The 60–30-10 challenge. BMC Med. 2020;18:1–8.

Article   Google Scholar  

King D, Wittenberg R, Patel A, Quayyum Z, Berdunov V, Knapp M. The future incidence, prevalence and costs of stroke in the UK. Age Ageing. 2020;49:277–82.

Ganesh A, Lindsay P, Fang J, Kapral MK, Cote R, Joiner I, et al. Integrated systems of stroke care and reduction in 30-day mortality: A retrospective analysis. Neurology. 2016;86:898–904.

Lowther HJ, Harrison J, Hill JE, Gaskins NJ, Lazo KC, Clegg AJ, et al. The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: A systematic review. Implement Sci. 2021;16:16.

Australian Commission on Safety and Quality in Health Care. Acute stroke clinical care standard. 2015. Available from https://www.safetyandquality.gov.au/our-work/clinical-care-standards/acute-stroke-clinical-care-standard . Accessed Jan 2024.

Australian Commission on Safety and Quality in Health Care. Acute stroke clinical care standard. Sydney: ACSQHC; 2019. Available from https://www.safetyandquality.gov.au/publications-and-resources/resource-library/acute-stroke-clinical-care-standard-evidence-sources . Accessed Jan 2024.

Ryan O, Ghuliani J, Grabsch B, Hill K, G CC, Breen S, et al. Development, implementation, and evaluation of the Australian Stroke Data Tool (AuSDaT): Comprehensive data capturing for multiple uses. Health Inf Manag. 2022:18333583221117184.

English C, Bayley M, Hill K, Langhorne P, Molag M, Ranta A, et al. Bringing stroke clinical guidelines to life. Int J Stroke. 2019;14:337–9.

English C, Hill K, Cadilhac DA, Hackett ML, Lannin NA, Middleton S, et al. Living clinical guidelines for stroke: Updates, challenges and opportunities. Med J Aust. 2022;216:510–4.

Cadilhac DA, Grimley R, Kilkenny MF, Andrew NE, Lannin NA, Hill K, et al. Multicenter, prospective, controlled, before-and-after, quality improvement study (Stroke123) of acute stroke care. Stroke. 2019;50:1525–30.

Cadilhac DA, Marion V, Andrew NE, Breen SJ, Grabsch B, Purvis T, et al. A stepped-wedge cluster-randomized trial to improve adherence to evidence-based practices for acute stroke management. Jt Comm J Qual Patient Saf. 2022.

Elliott J, Lawrence R, Minx JC, Oladapo OT, Ravaud P, Jeppesen BT, et al. Decision makers need constantly updated evidence synthesis. Nature. 2021;600:383–5.

Article   CAS   PubMed   Google Scholar  

National Stroke Foundation. National guidelines for acute stroke management. Melbourne: National Stroke Foundation; 2003.

National Stroke Foundation. Clinical guidelines for stroke rehabilitation and recovery. Melbourne: National Stroke Foundation; 2005.

Phan TG, Thrift A, Cadilhac D, Srikanth V. A plea for the use of systematic review methodology when writing guidelines and timely publication of guidelines. Intern Med J . 2012;42:1369–1371; author reply 1371–1362

Tendal B, Vogel JP, McDonald S, Norris S, Cumpston M, White H, et al. Weekly updates of national living evidence-based guidelines: Methods for the Australian living guidelines for care of people with COVID-19. J Clin Epidemiol. 2021;131:11–21.

Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7:50.

Harris D, Cadilhac D, Hankey GJ, Hillier S, Kilkenny M, Lalor E. National stroke audit: The Australian experience. Clin Audit. 2010;2:25–31.

Cadilhac DA, Purvis T, Kilkenny MF, Longworth M, Mohr K, Pollack M, et al. Evaluation of rural stroke services: Does implementation of coordinators and pathways improve care in rural hospitals? Stroke. 2013;44:2848–53.

Cadilhac DA, Moss KM, Price CJ, Lannin NA, Lim JY, Anderson CS. Pathways to enhancing the quality of stroke care through national data monitoring systems for hospitals. Med J Aust. 2013;199:650–1.

Cadilhac DA, Lannin NA, Anderson CS, Levi CR, Faux S, Price C, et al. Protocol and pilot data for establishing the Australian Stroke Clinical Registry. Int J Stroke. 2010;5:217–26.

Ivers N, Jamtvedt G, Flottorp S, Young J, Odgaard-Jensen J, French S, et al. Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev . 2012

Australian Commission on Safety and Quality in Health Care. Economic evaluation of clinical quality registries. Final report. . 2016:79

Cadilhac DA, Dalli LL, Morrison J, Lester M, Paice K, Moss K, et al. The Australian Stroke Clinical Registry annual report 2021. Melbourne; 2022. Available from https://auscr.com.au/about/annual-reports/ . Accessed 6 May 2024.

Kilkenny MF, Kim J, Andrew NE, Sundararajan V, Thrift AG, Katzenellenbogen JM, et al. Maximising data value and avoiding data waste: A validation study in stroke research. Med J Aust. 2019;210:27–31.

Eliakundu AL, Smith K, Kilkenny MF, Kim J, Bagot KL, Andrew E, et al. Linking data from the Australian Stroke Clinical Registry with ambulance and emergency administrative data in Victoria. Inquiry. 2022;59:469580221102200.

PubMed   Google Scholar  

Andrew NE, Kim J, Cadilhac DA, Sundararajan V, Thrift AG, Churilov L, et al. Protocol for evaluation of enhanced models of primary care in the management of stroke and other chronic disease (PRECISE): A data linkage healthcare evaluation study. Int J Popul Data Sci. 2019;4:1097.

CAS   PubMed   PubMed Central   Google Scholar  

Mosalski S, Shiner CT, Lannin NA, Cadilhac DA, Faux SG, Kim J, et al. Increased relative functional gain and improved stroke outcomes: A linked registry study of the impact of rehabilitation. J Stroke Cerebrovasc Dis. 2021;30: 106015.

Ryan OF, Hancock SL, Marion V, Kelly P, Kilkenny MF, Clissold B, et al. Feedback of aggregate patient-reported outcomes (PROs) data to clinicians and hospital end users: Findings from an Australian codesign workshop process. BMJ Open. 2022;12:e055999.

Grimley RS, Rosbergen IC, Gustafsson L, Horton E, Green T, Cadigan G, et al. Dose and setting of rehabilitation received after stroke in Queensland, Australia: A prospective cohort study. Clin Rehabil. 2020;34:812–23.

Purvis T, Middleton S, Craig LE, Kilkenny MF, Dale S, Hill K, et al. Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a national audit for acute stroke: Evidence of upscale and spread. Implement Sci. 2019;14:87.

Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D’Este C, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): A cluster randomised controlled trial. Lancet. 2011;378:1699–706.

Middleton S, Dale S, Cheung NW, Cadilhac DA, Grimshaw JM, Levi C, et al. Nurse-initiated acute stroke care in emergency departments. Stroke. 2019:STROKEAHA118020701.

Hood RJ, Maltby S, Keynes A, Kluge MG, Nalivaiko E, Ryan A, et al. Development and pilot implementation of TACTICS VR: A virtual reality-based stroke management workflow training application and training framework. Front Neurol. 2021;12:665808.

Bladin CF, Kim J, Bagot KL, Vu M, Moloczij N, Denisenko S, et al. Improving acute stroke care in regional hospitals: Clinical evaluation of the Victorian Stroke Telemedicine program. Med J Aust. 2020;212:371–7.

Bladin CF, Bagot KL, Vu M, Kim J, Bernard S, Smith K, et al. Real-world, feasibility study to investigate the use of a multidisciplinary app (Pulsara) to improve prehospital communication and timelines for acute stroke/STEMI care. BMJ Open. 2022;12:e052332.

Zhao H, Coote S, Easton D, Langenberg F, Stephenson M, Smith K, et al. Melbourne mobile stroke unit and reperfusion therapy: Greater clinical impact of thrombectomy than thrombolysis. Stroke. 2020;51:922–30.

Purvis T, Cadilhac DA, Hill K, Reyneke M, Olaiya MT, Dalli LL, et al. Twenty years of monitoring acute stroke care in Australia from the national stroke audit program (1999–2019): Achievements and areas of future focus. J Health Serv Res Policy. 2023.

Cadilhac DA, Purvis T, Reyneke M, Dalli LL, Kim J, Kilkenny MF. Evaluation of the national stroke audit program: 20-year report. Melbourne; 2019.

Kim J, Tan E, Gao L, Moodie M, Dewey HM, Bagot KL, et al. Cost-effectiveness of the Victorian Stroke Telemedicine program. Aust Health Rev. 2022;46:294–301.

Kim J, Easton D, Zhao H, Coote S, Sookram G, Smith K, et al. Economic evaluation of the Melbourne mobile stroke unit. Int J Stroke. 2021;16:466–75.

Stroke Foundation. National stroke audit – rehabilitation services report 2020. Melbourne; 2020.

Australian Institute of Health and Welfare. Heart, stroke and vascular disease: Australian facts. 2023. Webpage https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/hsvd-facts/contents/about (accessed Jan 2024).

Download references

Acknowledgements

The following authors hold National Health and Medical Research Council Research Fellowships: HT (#2009326), DAC (#1154273), SM (#1196352), MFK Future Leader Research Fellowship (National Heart Foundation #105737). The Funders of this work did not have any direct role in the design of the study, its execution, analyses, interpretation of the data, or decision to submit results for publication.

Author information

Helena Teede and Dominique A. Cadilhac contributed equally.

Authors and Affiliations

Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia

Helena Teede, Emily Callander & Joanne Enticott

Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia

Helena Teede & Alison Johnson

Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia

Dominique A. Cadilhac, Tara Purvis & Monique F. Kilkenny

Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia

Dominique A. Cadilhac, Monique F. Kilkenny & Bruce C.V. Campbell

Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia

Bruce C.V. Campbell

Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia

School of Health Sciences, Heart and Stroke Program, University of Newcastle, Hunter Medical Research Institute, University Drive, Callaghan, NSW, Australia

Coralie English

School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia

Rohan S. Grimley

Clinical Excellence Division, Queensland Health, Brisbane, Australia

John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Sydney, NSW, Australia

Christopher Levi

School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia

Sandy Middleton

Nursing Research Institute, St Vincent’s Health Network Sydney and and Australian Catholic University, Sydney, NSW, Australia

Stroke Foundation, Level 7, 461 Bourke St, Melbourne, VIC, Australia

Kelvin Hill

You can also search for this author in PubMed   Google Scholar

Contributions

HT: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. DAC: conception, design and initial draft, provided essential literature and case study examples, approved the submitted version. TP: revised the manuscript critically for important intellectual content, approved the submitted version. MFK: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. BC: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. CE: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. AJ: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. EC: revised the manuscript critically for important intellectual content, approved the submitted version. RSG: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. CL: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. SM: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. KH: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. JE: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. All authors read and approved the final manuscript.

Authors’ Twitter handles

@HelenaTeede

@DominiqueCad

@Coralie_English

@EmilyCallander

@EnticottJo

Corresponding authors

Correspondence to Helena Teede or Dominique A. Cadilhac .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests, additional information, publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Teede, H., Cadilhac, D.A., Purvis, T. et al. Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke. BMC Med 22 , 198 (2024). https://doi.org/10.1186/s12916-024-03416-w

Download citation

Received : 23 July 2023

Accepted : 30 April 2024

Published : 15 May 2024

DOI : https://doi.org/10.1186/s12916-024-03416-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Evidence-based medicine
• Person-centred care
• Models of care
• Healthcare improvement

BMC Medicine

ISSN: 1741-7015

• Submission enquiries: [email protected]
• General enquiries: [email protected]

An official website of the Department of Health & Human Services

• Search All AHRQ Sites
• Email Updates

1. Use quotes to search for an exact match of a phrase.

2. Put a minus sign just before words you don't want.

3. Enter any important keywords in any order to find entries where all these terms appear.

• The PSNet Collection
• All Content
• Perspectives
• Current Weekly Issue
• Past Weekly Issues
• Curated Libraries
• Clinical Areas
• Patient Safety 101
• The Fundamentals
• Training and Education
• Continuing Education
• WebM&M: Case Studies
• Training Catalog
• Submit a Case
• Improvement Resources
• Innovations
• Submit an Innovation
• About PSNet
• Editorial Team
• Technical Expert Panel

Leading quality and safety on the frontline - a case study of department leaders in nursing homes.

Magerøy M, Braut GS, Macrae C, et al. Leading quality and safety on the frontline - a case study of department leaders in nursing homes. J Healthc Leadersh. 2024;16:193-208. doi:10.2147/jhl.s454109.

Nursing homes face serious, ongoing patient safety challenges. This qualitative data analysis identified challenges and facilitators that are experienced by nursing home leaders in Norway as they manage the dual responsibilities of Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS). The analysis identified four themes – temporal capacity, relational capacity, professional competence , and organizational structure – highlighting the importance of adequate resources , teamwork, and strong organizational safety culture .

Healthcare leaders' and elected politicians' approach to support-systems and requirements for complying with quality and safety regulation in nursing homes - a case study. September 13, 2023

Managing patient safety and staff safety in nursing homes: exploring how leaders of nursing homes negotiate their dual responsibilities- a case study. February 28, 2024

Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators of resilience. April 14, 2021

Resilience from a stakeholder perspective: the role of next of kin in cancer care. September 23, 2020

Positive deviance: a different approach to achieving patient safety. August 20, 2014

Determination of health-care teamwork training competencies: a Delphi study. December 2, 2009

Naming the "baby" or the "beast"? The importance of concepts and labels in healthcare safety investigation. April 5, 2023

Issues and complexities in safety culture assessment in healthcare. July 19, 2023

The patient died: what about involvement in the investigation process? June 24, 2020

Tools for establishing a sustainable safety culture within maternity services: a retrospective case study. April 26, 2023

Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths October 2, 2019

Back to basics: checklists in aviation and healthcare. June 17, 2015

Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. January 14, 2009

Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. January 7, 2015

Designing and pilot testing of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD intervention). August 14, 2019

Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative study in five countries. March 27, 2013

Linking transformational leadership, patient safety culture and work engagement in home care services. January 29, 2020

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties. March 18, 2020

Exploring challenges in quality and safety work in nursing homes and home care - a case study as basis for theory development. April 29, 2020

Family perceptions of medication administration at school: errors, risk factors, and consequences. April 16, 2008

Remembering to learn: the overlooked role of remembrance in safety improvement. December 7, 2016

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. July 10, 2019

Learning from failure: the need for independent safety investigation in healthcare. November 19, 2014

The problem with incident reporting. October 28, 2015

Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety. June 5, 2019

Can we import improvements from industry to healthcare? May 1, 2019

Governing the safety of artificial intelligence in healthcare. May 8, 2019

The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems. June 9, 2010

Early warnings, weak signals and learning from healthcare disasters. April 9, 2014

Imitating incidents: how simulation can improve safety investigation and learning from adverse events. June 27, 2018

Measurement and monitoring of safety: impact and challenges of putting a conceptual framework into practice. April 11, 2018

Safety analysis over time: seven major changes to adverse event investigation. January 24, 2018

Learning from patient safety incidents: creating participative risk regulation in healthcare. February 27, 2008

Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals. October 28, 2009

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation. August 6, 2008

Transformational improvement in quality care and health systems: the next decade. November 25, 2020

"Time is of the essence": relationship between hospital staff perceptions of time, safety attitudes and staff wellbeing. December 8, 2021

Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals. September 1, 2021

Unsafe care in residential settings for older adults. A content analysis of accreditation reports. December 13, 2023

Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts. December 6, 2023

Predictors of response rates of safety culture questionnaires in healthcare: a systematic review and analysis. October 26, 2022

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. August 16, 2023

COVID-19: patient safety and quality improvement skills to deploy during the surge. June 24, 2020

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. May 27, 2020

Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals. October 8, 2014

Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. May 21, 2014

'Between the flags': implementing a rapid response system at scale. May 14, 2014

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study. March 24, 2010

Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers. January 30, 2005

Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors. February 9, 2011

Beyond patient safety Flatland. June 30, 2010

Cultural and associated enablers of, and barriers to, adverse incident reporting. June 23, 2010

Nurses' workarounds in acute healthcare settings: a scoping review. June 19, 2013

Investigating patient safety culture across a health system: multilevel modelling of differences associated with service types and staff demographics. July 25, 2012

Analysis of Australian newspaper coverage of medication errors. January 25, 2012

Health professional networks as a vector for improving healthcare quality and safety: a systematic review. January 11, 2012

Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study. February 15, 2012

'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations. May 9, 2018

Changing how we think about healthcare improvement. June 13, 2018

Association between organisational and workplace cultures, and patient outcomes: systematic review. January 17, 2018

The application of the Global Trigger Tool: a systematic review. October 26, 2016

False dawns and new horizons in patient safety research and practice. December 20, 2017

Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals. May 6, 2009

A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity. May 31, 2006

Attitudes toward the large-scale implementation of an incident reporting system. April 9, 2008

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. December 20, 2006

Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. October 26, 2005

The effect of physicians' long-term use of CPOE on their test management work practices. September 27, 2006

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices. June 30, 2021

Educational levels of hospital nurses and surgical patient mortality. April 3, 2005

A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals. November 1, 2023

Quality gaps identified through mortality review. February 1, 2017

Assessing the impact of teaching patient safety principles to medical students during surgical clerkships. July 20, 2011

Medical errors: mandatory reporting, voluntary reporting, or both? August 10, 2005

Journal Article

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. May 19, 2021

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. April 12, 2023

Handoff practices in emergency medicine: are we making progress? March 23, 2016

Preventability and causes of readmissions in a national cohort of general medicine patients. May 4, 2016

Project BOOST implementation: lessons learned. September 10, 2014

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. October 27, 2010

Process changes to increase compliance with the Universal Protocol for bedside procedures. June 1, 2011

Single-parameter early warning criteria to predict life-threatening adverse events. June 23, 2010

Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. November 27, 2013

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. July 18, 2012

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. May 23, 2012

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. August 21, 2013

A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). July 31, 2013

Design and implementation of an automated email notification system for results of tests pending at discharge. February 29, 2012

The impact of automated notification on follow-up of actionable tests pending at discharge: a cluster-randomized controlled trial. April 11, 2018

Curriculum development and implementation of a national interprofessional fellowship in patient safety. September 5, 2018

Readiness of US general surgery residents for independent practice. October 4, 2017

The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program. June 14, 2017

Medication safety in a psychiatric hospital. March 21, 2007

A controlled trial of a rapid response system in an academic medical center. June 25, 2008

Adverse events related to accidental unintentional ingestions from cough and cold medications in children. August 26, 2020

Evaluation of older persons' medications: a critical incident technique study exploring healthcare professionals' experiences and actions. June 23, 2021

Nurses' experience with presenteeism and the potential consequences on patient safety: a qualitative study among nurses at out-of-hours emergency primary care facilities. January 10, 2024

Medication dosage calculation among nursing students: does digital technology make a difference? A literature review. September 14, 2022

Clinical efficacy of combined surgical patient safety system and the World Health Organization's checklists in surgery: a nonrandomized clinical trial. June 3, 2020

Patient Safety Primers

Long-term Care and Patient Safety

Annual Perspective

Special Section: IEA Health Care 2021. February 28, 2024

Patient safety in nursing homes from an ecological perspective: an integrated review. January 17, 2024

National Healthcare Quality and Disparities Reports. January 9, 2024

Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey. December 20, 2023

The relationship between nursing home staffing and resident safety outcomes: a systematic review of reviews. December 6, 2023

Innovative approaches to analysing aged care falls incident data: International Classification for Patient Safety and correspondence analysis. November 8, 2023

Early identification and evaluation of severe pressure injuries. October 18, 2023

Exploring medication safety structures and processes in nursing homes: a cross-sectional study. August 30, 2023

Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety. August 16, 2023

Long-term care healthcare-associated infections in 2022: an analysis of 20,216 reports. May 24, 2023

WebM&M Cases

Efforts to improve the safety culture of the elderly in nursing homes: a qualitative study. April 19, 2023

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives. February 15, 2023

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes. February 15, 2023

Surveys on Patient Safety Culture Nursing Home Survey: 2023 User Database Report. February 8, 2023

Nursing home patient safety culture perceptions among licensed practical nurses. February 1, 2023

Interventions to increase patient safety in long-term care facilities-umbrella review. January 25, 2023

Patient safety measurement tools used in nursing homes: a systematic literature review. December 7, 2022

Patient safety culture in assisted living: staff perceptions and association with state regulations. November 30, 2022

Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators. October 5, 2022

Nursing Home Survey on Patient Safety Culture. August 31, 2022

Accuracy of pressure ulcer events in US nursing home ratings. August 24, 2022

Using health information technology in residential aged care homes: an integrative review to identify service and quality outcomes. August 17, 2022

Communication disparities between nursing home team members. July 20, 2022

Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports. July 13, 2022

Supplemental Item Set for Nursing Home SOPS: Call for Pilot Participants. July 6, 2022

Connect With Us

Sign up for Email Updates

To sign up for updates or to access your subscriber preferences, please enter your email address below.

Agency for Healthcare Research and Quality

5600 Fishers Lane Rockville, MD 20857 Telephone: (301) 427-1364

• Accessibility
• Disclaimers
• Electronic Policies
• HHS Digital Strategy
• HHS Nondiscrimination Notice
• Inspector General
• Plain Writing Act
• Privacy Policy
• Viewers & Players
• U.S. Department of Health & Human Services
• The White House
• Don't have an account? Sign up to PSNet

Submit Your Innovations

Please select your preferred way to submit an innovation.

Continue as a Guest

Track and save your innovation

in My Innovations

Edit your innovation as a draft

Continue Logged In

Please select your preferred way to submit an innovation. Note that even if you have an account, you can still choose to submit an innovation as a guest.

Continue logged in

New users to the psnet site.

Access to quizzes and start earning

CME, CEU, or Trainee Certification.

Get email alerts when new content

matching your topics of interest

in My Innovations.