care plan presentation

Nursing Care Plan

Jul 14, 2014

5.3k likes | 17.69k Views

Nursing Care Plan. Preferred College of Nursing. Prepared By : Meraljane Paras. NURSING PROCESS =. SCIENTIFIC METHOD + CRITICAL THINKING. STEPS IN NURSING PROCESS. Assessment Nursing Diagnosis Planning Intervention Evaluation. ASSESSMENT. Systematic and continuous collection of data.

Share Presentation

• part statement
• actual nursing diagnosis
• rape trauma
• impaired tissue integrity
• syndrome diagnosis

Presentation Transcript

Nursing Care Plan Preferred College of Nursing Prepared By : Meraljane Paras

NURSINGPROCESS = SCIENTIFIC METHOD + CRITICAL THINKING

STEPS IN NURSING PROCESS • Assessment • Nursing Diagnosis • Planning • Intervention • Evaluation

ASSESSMENT • Systematic and continuous collection of data

NURSING DIAGNOSIS • The statement of the clients actual or potential problem

PLANNING • The development of goals for care and possible activities to meet them

INTERVENTION • The giving of the actual nursing care

EVALUATION • The measurement of the effectiveness of nursing care

Activity 1 • Identify what step in the nursing process are the following? • Pain related to myocardial ischemia as manifested by guarding left chest, grimacing, moaning pain score of 10/10, Bp 170/80 HR 123 • -nursing diagnosis

At the end of the shift the patient will be able to ambulate at the end of the hallway. • planning/expected outcome

Pulse rate of 150 and irregular • assessment

Ambulate patient TID • intervention

Decreased use of accessory muscles; client reporting a decreased in shortness of breath and decrease in difficulty breathing? Goal met • evaluation

NURSING CARE PLAN • Formal guideline for directing nursing staff to provide client care • purpose of a nursing care plan is to identify problems of a patient and find solutions to the problems

NURSING CARE PLANPatient’s Initials____ Diagnosis ___________

Nursing Diagnosis 5 kinds of nursing diagnosis • Actual • Risk Potential nursing diagnoses • Possible nursing diagnoses • Wellness diagnoses • Syndrome diagnoses

Actual Diagnoses the persons data base contains evidence of signs and symptoms or defining characteristics of the diagnoses • 3 part statement • PES (Problem + etiology + signs and symptoms)

Example of actual nursing diagnosis Nursing diagnosis/ related to/ as manifested by Ineffective airway clearance/related to physiologic effects of pneumonia/ as evidenced by increased sputum, coughing, abnormal breath sounds, tachypnea, and dyspnea

Risk diagnosis • The persons data base contains evidence of related (risk factors of the diagnosis, but no evidence of the defining characteristics • Problem + etiology • Risk for impaired skin integrity/ related to obesity, excessive diaphoresis and confinement to bed • No signs and symptoms

Possible diagnosis • The person’s data base doesn’t demonstrate the defining characteristics or related factors of the diagnosis, but your intuition tells you the diagnosis may be present One part statement and simply name the possible problem • Ex. Possible ineffective individual coping

Wellness diagnoses • Being able to diagnose wellness diagnoses is based on recognizing when healthy clients indicate a desire to achieve a higher level of functioning in a specific area • One part statement use the word potential for enhanced Pt says I wish I were a better parent Nursing diagnosis: Potential for enhanced parenting

Syndrome diagnosis • There are only two syndrome diagnosis on the NANDA list • Disuse syndrome • Rape and trauma syndrome You use a syndrome diagnosis when the diagnosis is associated with a cluster of other diagnosis (often seen in bedridden nursing home care residents) It is a one part statement. Simply name the syndrome

Nursing Diagnoses associated with disuse syndrome • Impaired physical mobility • Risk for constipation • Risk for altered respiratory function • risk for infection • Risk for activity intolerance • Risk for injury • Risk for altered thought process • Risk for body image disturbance • Risk for powerlessness • Risk for impaired tissue integrity

Activity 2 Identify what kind of nursing diagnosis Impaired communication/ related to language barrier/ as evidenced by inability to speak or understand English and use of Spanish actual nursing diagnosis

Possible altered sexuality pattern • Possible nursing diagnosis

Rape trauma syndrome Syndrome diagnosis

Potential for enhanced care giver • Wellness diagnoses

Risk for aspiration related to impaired swallowing • Risk nursing diagnoses

Activity #3 • Identify if the statement is correct. If not correct the statement • risk for injury related to lack of the side rails on bed X do not write statement in such a way that it may be legally incriminating √: risk for injury related to disorientation

Rape trauma syndrome √ One part statement only

Mastectomy related to cancer X do not state the nursing diagnosis using medical terminology. Focus on the persons response to medical problems √:Risk for self concept disturbance related to effects of the mastectomy

Pain and fear related to diagnostic procedure X do not state two problem at the same time √:fear related unfamiliarity with diagnostic procedures pain related to diagnostic procedure

Risk for confinement related to confinement to bed √ One part statement only

Spiritual distress related to atheism as evidenced by statements that she has never believe in GOD X don’t write a nursing diagnosis based on value judgment √:there may be no diagnosis in this situation. The person may be at peace with her beliefs not with yours

Planning/ expected outcome • Components of expected Outcome • Subject: Who is the person expected to achieve the outcome? • Verb: What actions must the person take to achieve the outcome? • Condition; Under what circumstances is the person to perform the actions? • Performance criteria: How well is the person to perform the actions: • Target time: By when is the person expected to be able to perform the actions?

Planning/ expected outcome Mr. Smith will walk with a cane at least to the end of the hall and back by Friday • Subject: Mr. Smith • Verb: will walk • Condition; with a cane • Performance criteria at least to the end of the hall and back • Target time: by Friday

Measurable verbs • Share • Express • Will loose • Will gain • Has an absence of • Exercise • Communicate • Cough • Walk • Stand sit • Identify • Describe • Perform • Relate • State • List • Verbalize • Hold • Demonstrate

Non measurable verbs (Do not use) • Know • Understand • Appreciate • Think • Accept • feel

Identify if the statement are written correctly • John will know the four basic food groups by 6/30/07 X • The verb is not measurable • √John will list the four basic food groups by 6/30/07

Identify if the statement are written correctly • Mrs. S will demonstrate how to use her walker unassisted by saturday √ • Subject: Mrs. S • Verb: will demonstrate • Condition; will use her walker • Performance criteria unassisted • Target time: by Saturday

Identify if the statement are written correctly • After 1 hour Mrs. G will verbalize decrease level of pain from 10/10 to 3/10. √ • Subject: Mrs G • Verb: will verbalize • Condition; decrease level of pain • Performance criteria from 10/10 to 3/10 • Target time: after 1 hour

NURSING CARE PLANPatient’s Initials_J.R.__Diagnosis ___________

Activity # 4 write a care plan for the following problem. • 1. Pt who has diarrhea • 2. Pt who is constipated • 3. Pt who has a fever • 4. Pt who has stage II decubitus ulcer • 5. Pt who is in pain or create a care plan using • Ineffective airway clearance • Risk for aspiration • Risk for infection • Impaired physical mobility

Activity #5 PRACTISE QUESTIONS 1.) A Nurse is assigned to care for a patient receiving enteral feedings. The nurse plans care knowing that which of the following is a highest priority for the client a.) altered nutrition b.) risk for aspiration c.) risk for fluid volume deficit d.) risk for diarrhea

Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Options 1 and 4 maybe appropriate nursing diagnoses but are not of highest priority. Option 3 is not likely to occur

The nurse is teaching a client with diabetes mellitus about dietary measures to follow. The client express frustration in learning the dietary regimen. The nurse would initially 1. Identify the cause of the frustration 2. Continue with the dietary teaching 3. Notify the physician 4. Tell the client that the diet needs to be followed

• More by User

NURSING HOME CARE

NURSING HOME CARE. Swedish Family Medicine October 10, 2000 Pat Borman, MD . GOALS. Review the historical perspectives of nursing home care in the USA Understand the roles of physicians in providing nursing home care

3.5k views • 17 slides

Antepartal Nursing Care

Antepartal Nursing Care. Lunar month- 4 weeks, 28 days. OB Terminology . Pregnancy – divided into 3 trimesters 13 weeks each EDC - estimated date of confinement EDB - estimated date of birth *same thing Gestation - number of weeks since first day of last menstrual period

1.35k views • 33 slides

PEDIATRIC NURSING CARE

OUT LINE :-. Introduction Nursing processImportant of knowledge about growth and development Principle of growth

790 views • 17 slides

Perioperative Nursing Care

Perioperative Nursing Care. Perioperative Nursing Care. Perioperative refers to the management and treatment of the client during the three phases of surgery : Preoperative Phase Intraoperative Phase Postoperative Phase.

11.51k views • 47 slides

INTEGUMENTARY Nursing care

INTEGUMENTARY Nursing care. PN 124. INFECTIOUS DISORDERS. OBJECTIVES Discuss signs and symptoms or infectious disorders of the skin Define the nursing management of the client with infectious disorders of the skin

483 views • 24 slides

A Community Health Nursing Plan of Care

Lack of Health Care Providers In Mecosta County . A Community Health Nursing Plan of Care . Pam Beringer, Erin Burdi, Debra Francik , and Ashley Jacobson. Assessment & Analysis. Epidemiological Concepts

1.04k views • 86 slides

AMBULATORY CARE NURSING

AMBULATORY CARE NURSING. Presented by Lindy Peterson, RN. References. McEwen, M. (2002). Community-based nursing: An introduction (2nd ed.). Philadelphia, PA: Saunders. Chapter 3: Nursing Care in Ambulatory Settings. Competencies for Ch 3 Ambulatory Settings.

593 views • 13 slides

Nursing Care :

Nursing Care :. for Pregnant’s Woman with Preterm Labor Pain. By. Thanima Sungsuwan Hatyai Hospital Songkhla 1998. Definition.

638 views • 23 slides

Lack of Health Care Providers In Mecosta County. A Community Health Nursing Plan of Care. Pam Beringer, Erin Burdi, Debra Francik , and Ashley Jacobson. Assessment & Analysis. Epidemiological Concepts

1.21k views • 86 slides

NURSING HOME CARE. Swedish Family Medicine October 10, 2000 Pat Borman, MD. GOALS. Review the historical perspectives of nursing home care in the USA Understand the roles of physicians in providing nursing home care

534 views • 17 slides

Critical Healthcare Solutions | Nursing Care Plan For Diabetes

Home health care services like home nursing are made easy and assessble to all by Rxpress! Reach us for home nursing and online medicine and much more!

259 views • 11 slides

Nursing Care | Nursing Care Service | Nursing Care Services

Garima Patient Care Services provides the new born baby care services, Patient Care Services, nursing care services in Gurgaon. We provide 24 hours emergency services for our patient in Gurgaon.

353 views • 1 slides

Critical Care Nursing

The majority of everyday care that patients in critical condition receive is performed by dedicated critical care nurses. Read here for more information http://physical-health-tips.blogspot.com/2017/01/critical-care-nursing.html

726 views • 11 slides

Postpartum Nursing Care

Postpartum Nursing Care. Pathophysiological and Psychosocial Changes of Postpartum Postpartum Assessment and Caring Interventions Laboratory Values of the Postpartum Client Medications used in Postpartum Physiology of breastfeeding and the Breastfeeding client Formula Feeding

865 views • 63 slides

Nursing Diagnosis, Planning Nursing Care

Nursing Diagnosis, Planning Nursing Care. NURSING DIAGNOSIS. a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes The goal of a nursing diagnosis is to identify actual and potential responses.

1.18k views • 31 slides

Basics Of Care Plan By Nursing Care Plan Assignment Helpers

The nursing care plan is a written document that presents information about clients in an organised and meaningful way. It contains information about actions that nurses have to take for addressing clients' diagnoses. If you are also the one who is looking for Nursing care plan Assignment assistance, then you can get in touch with these experts by visiting at My assignment services.If you any query please mail - [email protected]

237 views • 8 slides

Emergency Nursing Care

Large base care taker for patient at home available at Blue Line Healthcare. Each of our experienced and licensed nurses will assist patients with their needs along with long term disability, Daily Living activities, Suffering from old age disease, emotional support as a friend by their side and many others.

285 views • 6 slides

Skilled Nursing Care

Athulya is a luxury old age homes in India with excellent assisted living features. It provides the best post-retirement life with round the clock medical attention. http://www.athulyaliving.com/nurse-service.php

112 views • 7 slides

Care Nursing

A care nursing is a health care provider who is trained to care for the elderly and is also known as a geriatric nurse or gerontologist.

360 views • 1 slides

University Administration

• Careers @ USA
• For Current Students
• Request Information
• Master of Occupational Therapy (MOT)
• Doctor of Occupational Therapy (OTD)
• Post-Professional Doctor of Occupational Therapy (PPOTD)
• Master of Health Administration (MHA)
• Doctor of 
Education (EdD)
• Graduate Certificates
• Clinical Orthopedic Residency (OCS)
• Orthopaedic Manual Physical Therapy Fellowship (OMPT)
• Continuing Professional Education (CPE)
• Doctor of Physical Therapy (DPT)
• Non-Degree Physical Therapy Online Courses
• Master of Science in Speech-Language Pathology (MS-SLP)
• Post-Graduate Nursing Certificates
• Master of Science in Nursing (MSN)
• Doctor of Nursing Practice (DNP)
• Browse All Degree-Programs
• Admissions & Aid Home
• Scholarships & Grants
• How to Apply
• Cost of Attendance
• Financial Aid
• Application Deadlines
• Academic Calendar
• Financial Aid FAQ
• Admissions FAQs
• Catalog/Handbook
• Our History
• Accreditation
• B Corp Certified
• Change of Ownership
• Student Achievement Data
• Institutional Learning Outcomes (ILOs)
• Diversity & Inclusion
• San Marcos, California
• St. Augustine, Florida
• Miami, Florida
• Austin, Texas
• Dallas, Texas
• Our Faculty
• Board of Directors

How to Write a Care Plan: A Guide for Nurses

Care plans are a way to strategically approach and streamline the nursing process. They also enable effective communication in a nursing team. This guide will help you understand the fundamentals of nursing care plans and how to create them, step by step. We’ll also outline best practices to keep in mind and provide you with a nursing care plan sample that you can download and print.

Table of Contents

What Is a Nursing Care Plan?

What are the components of a care plan, care plan fundamentals, sample nursing care plan.

A nursing care plan documents the process of identifying a patient’s needs and facilitating holistic care, typically according to a five-step framework. A care plan ensures collaboration among nurses, patients, and other healthcare providers. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/ )) ((Medical Dictionary for the Health Professions and Nursing, Farlex, “nursing care plan”, 2012: https://medical-dictionary.thefreedictionary.com/nursing+care+plan )) ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/ )) ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

Key Reasons to Have a Care Plan

The purpose of a nursing care plan is to document the patient’s needs and wants, as well as the nursing interventions (or implementations) planned to meet these needs. As part of the patient’s health record, the care plan is used to establish continuity of care. ((C. Björvell et al., “Development of an audit instrument for nursing care plans in the patient record,” Quality in Health Care , March 1, 2000: https://qualitysafety.bmj.com/content/qhc/9/1/6.full.pdf )) These are the main reasons to write a care plan:

• Patient-centered care 

A care plan helps nurses and other care team members organize aspects of patient care according to a timeline. It’s also a tool for them to think critically and holistically in a way that supports the patient’s physical, psychological, social, and spiritual care. Sometimes a patient should be assigned to a nurse with specific skills and experience; a care plan makes that process easier. For patients, having clear goals to achieve will make them more involved in their treatment and recovery. ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/ ))

• Nursing team collaboration

Writing a care plan allows a team of nurses (as well as physicians, assistants, and other care providers) to access the same information, share opinions, and collaborate to provide the best possible care for the patient. 

• Documentation and compliance

A well-written care plan allows nurses to measure the effectiveness of care and to record evidence that the care was given. This is important both to maximize care efficiency and to provide documentation for healthcare providers.

Care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation, and evaluation. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

Step 1: Assessment

The first step of writing a care plan requires critical thinking skills and data collection. Different healthcare organizations use different formats for the assessment phase. In general, the data you will collect here is both subjective (e.g., verbal statements) and objective (e.g., height and weight, intake/output). The source of the subjective data could be the patients or their caretakers, family members, or friends.

Nurses can gather data about the patient’s vital signs, physical complaints, visible body conditions, medical history, and current neurological functioning. Digital health records may help in the assessment process by populating some of this information automatically from previous records.

Step 2: Diagnosis

Using the collected data, you will develop a nursing diagnosis—which the North American Nursing Diagnosis Association (NANDA) defines as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.” ((NANDA, “Glossary of Terms”: https://nanda.org/publications-resources/resources/glossary-of-terms/ )) 

A nursing diagnosis sets the basis for choosing nursing actions to achieve specific outcomes. A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid ((Saul McLeod, “Maslow’s Hierarchy of Needs,” Simply Psychology , Dec. 29, 2020: https://www.simplypsychology.org/maslow.html )) (which identifies and ranks human needs) and helps prioritize treatments. For example, physiological needs (such as food, water, and sleep) are more fundamental to survival than love and belonging, self-esteem, and self-actualization, so they have the priority when it comes to nursing actions. ((Chiung-Yu Shih et al, “The association of sociodemographic factors and needs of haemodialysis patients according to Maslow’s hierarchy of needs,” Journal of Clinical Nursing , July 30, 2018: https://pubmed.ncbi.nlm.nih.gov/29777561/ ))

Based on the diagnosis, you’ll set goals (Step 3) to resolve the patient’s problems through nursing implementations (Step 4).

Step 3: Outcomes and Planning

After the diagnosis is the planning stage. Here, you will prepare SMART goals (more detail on this later) based on evidence-based practice (EBP) guidelines. You will consider the patient’s overall condition, along with their diagnosis and other relevant information, as you set goals for them to achieve desired and realistic health outcomes for the short and long term. 

Step 4: Implementation

Once you’ve set goals for the patient, it’s time to implement the actions that will support the patient in achieving these goals. The implementation stage consists of performing the nursing interventions outlined in the care plan. As a nurse, you will either follow doctors’ orders for nursing interventions or develop them yourself using evidence-based practice guidelines.

Interventions are classified into the following seven domains: family, behavioral, physiological, complex physiological, community, safety, and health system interventions. There are several basic interventions that you need to implement during each shift: pain assessment, changing the resting position, listening, cluster care, preventing falls, and fluid consumption.

Step 5: Evaluation

In the final step of a care plan, the health professional (who can be either a doctor or a nurse) will evaluate whether the desired outcome has been met. You will then adjust the care plan based on this information.

In a simple but useful way, Nurse.org explains the core questions your care plan should answer: what, why, and how. ((Mariam Yazdi, “4 Steps to Writing a Nursing Care Plan,” Nurse.org, March 23, 2018: https://nurse.org/articles/nursing-care-plan-how-to/ )) A nursing care plan should include:

• The What : What does the patient suffer from? What do they risk suffering from?
• The Why : Why does your patient suffer from this? Why do they risk suffering from this?
• The How : How can you make this better?

Successful care plans use the fundamental principles of critical thinking, client-centered techniques, goal-oriented strategies, evidence-based practice (EBP) recommendations, and nursing intuition. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

SMART Goals

In the planning phase of writing a care plan, it’s important that you use goal-oriented strategies. A SMART goals template can help in this process:

• Specific : Your goals for the patient must be well-defined and unambiguous. 
• Measurable : You need to set certain metrics to measure the patient’s progress toward these goals.
• Achievable : Their goal should be possible to achieve.
• Realistic : Their goals must be within reach and relevant to the overall care plan.
• Time-bound : The patient’s goals should have a clear starting time and end date (which can be flexible). 

Effective Communication

Unless your care plan is communicated effectively to all relevant stakeholders, it will only be a plan. Remember that the purpose of a nursing care plan is not to be a static document, but to guide the entire nursing process and enable teamwork, with the goal of improving care. Writing skills are crucially important for nurses—you’ll need to be as accurate and current as possible in your descriptions. For effective communication, keep in mind the following best practices when writing a care plan:

• Write down everything immediately so you don’t forget the details.
• Write clearly and concisely, using terms that your team will understand.
• Include dates and times.

Although you will learn communication skills in an undergraduate or graduate nursing program , you will also develop them over time and with practical experience. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Shareable and Easy to Access

Care plans also need to be easy to share with the relevant stakeholders—patients, doctors, other members of the nursing team, insurance companies, etc. The documentation format will vary according to hospital policy , but, in general, care plans are created in electronic format and integrated into the electronic health record (EHR) for easy access to everyone. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Finally, you will need to update your care plans often with the latest information. That implies checking in with patients frequently and recording data about how the patient is progressing toward their goals, which will be important in the evaluation stage of the care plan. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Despite the overall general objective, nursing care plans written by students are not the same as those created by registered nurses in clinical settings. The student version is much longer, has a greater level of detail, and is exhaustively thorough. On the other hand, nurses often assume some basic concepts and note some of the steps in the care plan only mentally. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/ ))

For example, in the interventions section, a student would write: “vital signs recorded every four hours: blood pressure, heart rate, three- or five-lead electrocardiograms, functional oxygen saturation, respiratory rate, and skin temperature,” while an experienced registered nurse might just write “Q4 vital signs.”

Why this difference? As a student or recent graduate, including all the information in your care plan will help you solidify your training. While writing care plans in school can be a very time-consuming task, mastering this information in nursing school will improve your competency and confidence. Most of the information that you’ll have to look up while you’re still in school will become second nature in the future. Here’s what a care plan written by a student looks like:

• Assessment : “heart rate 100 bpm, dyspnea, restlessness, guarding behavior.”
• Diagnosis : “impaired gas exchange RT collection of mucus in airway.”
• Outcomes and planning : “patient must maintain optimal gas exchange.”
• Implementations : “assess respiration; encourage breathing and position changes.”
• Rationale : “respiration will indicate the level of lung involvement, as the patient will adjust their breathing to facilitate gas exchange; these will improve ventilation and allow for chest expansion.”
• Evaluation : “the patient maintained good gas exchange, normal respiratory rate.”

Note that student care plans often have an additional column—rationale—where students note the scientific explanation for the implementations they chose. To help you get started with a care plan writing practice, we’ve created a printable nursing care plan, which you can use to practice writing all the steps outlined in this article.

Wrapping Up: Writing an Effective Nursing Care Plan

To be successful, a nursing plan needs effective communication, goal-oriented tasks, accessibility and shareability, and evidence-based practice. 

When it meets these qualities and is supported by the nurse’s intuition, critical thinking, and a general focus on the patient, a nursing care plan becomes a go-to resource for nurses to record and access all the information they need. A care plan is your roadmap for effective nursing care, and a collaboration tool that improves the entire healthcare process.

While all nursing programs teach the basics of writing a care plan, your communication, goal setting, and critical thinking skills will be shaped by the program you attend. 

For example, one of the benefits of writing care plans is that it will allow you to develop professionalism , along with important values like accountability, respect, and integrity. Key results of professionalism include better overall care, improved team communication, and a more positive work environment. ((Nursco, “Professionalism in Nursing – 5 Tips for Nurses,” July 13, 2018: https://www.nursco.com/professionalism-nursing-5-tips-nurses/ )) 

That’s why it’s important that you choose the right program for your needs—one that will help you develop communication and critical thinking skills, as well as professionalism, to be ready for the day-to-day nursing life. 

The University of St. Augustine for Health Sciences (USAHS) offers a Master of Science in Nursing degree (MSN), a Doctor of Nursing Practice degree (DNP), and Post-Graduate Nursing Certificates designed for working nurses. Our degrees are offered online, with optional on-campus immersions.* Role specialties include Family Nurse Practitioner (FNP), Nurse Educator ,** and Nurse Executive . The MSN has several options to accelerate your time to degree completion. Earn your advanced nursing degree while keeping your work and life in balance.

*The FNP role specialty includes two required hands-on clinical intensives as part of the curriculum.

**The Nurse Educator role specialty is not available for the DNP program.

Take charge of your own life-story

More Articles

Nurse Practitioner vs. Physician Assistant: Key Differences

85 Nursing Quotes: Words of Wisdom for Nurses

How To Study Effectively? 10 Best Study Techniques | USAHS

Upcoming events.

Doctor of Physical Therapy (DPT) Academic Webinar - August 13 | USAHS

Post Professional Doctor of Occupational Therapy (OTD) Webinar - August 13 | USAHS

Flex Doctor of Physical Therapy (Flex DPT) - Academic Webinar - August 14 | USAHS

How to Write a Nursing Care Plan

Nursing care plan components, nursing care plan fundamentals.

Knowing how to write a nursing care plan is essential for nursing students and nurses. Why? Because it gives you guidance on what the patient’s main nursing problem is, why the problem exists, and how to make it better or work towards a positive end goal. In this article, we'll dig into each component to show you exactly how to write a nursing care plan. 

Popular Online RN-to-BSN Programs

Enrollment: Nationwide

At Purdue Global, discover a faster, more affordable way to earn your Nursing degree. Purdue Global is committed to keeping your tuition costs as low as possible and helping you find the most efficient path to your degree.

Enrollment: Nationwide, but certain programs have state restrictions. Check with Purdue for details.

• RN-to-BSN - ExcelTrack

As a working RN, you need a flexible, transfer-friendly program to help you save time and money as you take the next step in your nursing career. In our CCNE-accredited4 RN to BSN program, you can transfer in up to 134 credits—which is nearly 75% of program requirements. Your transfer credits can be reviewed in one business day (on average).

Enrollment: FL

WGU's award-winning online programs are created to help you succeed while graduating faster and with less debt. WGU is a CCNE accredited, nonprofit university offering nursing bachelor's and master's degrees.

A nursing care plan has several key components including, 

• Nursing diagnosis
• Expected outcome
• Nursing interventions and rationales

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections otherwise, it won’t make sense!

• Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for their patients
• Expected outcome - The measurable action for a patient to be achieved in a specific time frame. 
• Nursing interventions and rationales - Actions to be taken to achieve expected outcomes and reasoning behind them.
• Evaluation - Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

>> Related: What is the Nursing Process?

Get 10% OFF Nursing School Study Guides From nurseinthemaking.com ! Fill out the form to get your exclusive discount.

Before writing a nursing care plan, determine the most significant problems affecting the patient. Think about medical problems but also psychosocial problems. At times, a patient's psychosocial concerns might be more pressing or even holding up discharge instead of the actual medical issues. 

After making a list of problems affecting the patient and corresponding nursing diagnosis, determine which are the most important. Generally, this is done by considering the ABCs (Airway, Breathing, Circulation). However, these will not ALWAYS be the most significant or even relevant for your patient. 

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective nursing data . Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable.

This information can come from, 

Verbal statements from the patient and family

Vital signs

Blood pressure

Respirations

Temperature

Oxygen Saturation

Physical complaints

Body conditions

Head-to-toe assessment findings

Medical history

Height and weight

Intake and output

Patient feelings, concerns, perceptions

Laboratory data

Diagnostic testing

Echocardiogram

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and the objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA), defines a nursing diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step. 

Get 5 FREE study guides from Simplenursing.com - fill out the form for instant access! 1. Fluid & Electrolytes study guide 2. EKG Rhythms study guide 3. Congestive Heart Failure study guide 4. Lab Values study guide 5. Metabolic Acidosis & Alkalosis study guide

By clicking download, you agree to receive email newsletters and special offers from Nurse.org & Simplenursing.com. You may unsubscribe at any time by using the unsubscribe link, found at the bottom of every email.

Your request has been received. Thanks!

There are 4 types of nursing diagnoses.  

Problem-focused - Patient problem present during a nursing assessment is known as a problem-focused diagnosis

Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem developing

Health promotion - Improve the overall well-being of an individual, family, or community

Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions

After determining which type of the four diagnoses you will use, start building out the nursing diagnosis statement. 

The three main components of a nursing diagnosis are:

Problem and its definition - Patient’s current health problem and the nursing interventions needed to care for the patient.

Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed

Defining characteristics or risk factors - Signs and symptoms that allow for applying a specific diagnostic label/used in the place of defining characteristics for risk nursing diagnosis

PROBLEM-FOCUSED DIAGNOSIS

Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

RISK DIAGNOSIS

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART is an acronym that stands for,

It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. A medical diagnosis is made by a physician or advanced healthcare practitioner.  It’s important to remember that a medical diagnosis does not change if the condition is resolved, and it remains part of the patient’s health history forever. 

Examples of medical diagnosis include, 

Chronic Lung Disease (CLD)

Alzheimer’s Disease

Endocarditis

Plagiocephaly 

Congenital Torticollis 

Chronic Kidney Disease (CKD)

It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal. 

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization. 

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories: 

Physiological

Complex physiological

Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

Pain assessment

Position changes

Fall prevention

Providing cluster care

Infection control

Step 5: Evaluation 

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes, 

Based on the evaluation, it can determine if the goals and interventions need to be altered. Ideally, by the time of discharge, all nursing care plans, including goals should be met. Unfortunately, this is not always the case - especially if a patient is being discharged to hospice, home care, or a long-term care facility. Initially, you will find that most care plans will have ongoing goals that might be met within a few days or may take weeks. It depends on the status of the patient as well as the desired goals. 

Consider picking goals that are achievable and can be met by the patient. This will help the patient feel like they are making progress but also provide relief to the nurse because they can track the patient’s overall progress. 

>> Show Me Online RN-to-BSN Programs

Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan. The nursing plan is constantly updated with changes and new subjective and objective data. 

Key aspects of the care plan include,

Outcome and Planning

Implementation

Through subjective and objective data, constantly assessing your patient’s physical and mental well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a helpful and powerful tool.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

Plus, get exclusive access to discounts for nurses, stay informed on the latest nurse news, and learn how to take the next steps in your career.

By clicking “Join Now”, you agree to receive email newsletters and special offers from Nurse.org. You may unsubscribe at any time by using the unsubscribe link, found at the bottom of every email.

How To Write the Perfect Nursing Care Plan with Examples

What are you struggling with in nursing school?

NURSING.com is the BEST place to learn nursing. With over 2,000+ clear, concise, and visual lessons, there is something for you!

Struggling to Write a Nursing Care Plan

I recently met a nursing student named, Sarah who had just started on her journey to become a nurse.  She was struggling with writing nursing care plans.  Sarah struggled with gathering comprehensive patient information, identifying appropriate nursing diagnoses, and formulating effective interventions.

Writing a nursing care plan is an essential skill that every nursing student should master. It serves as a roadmap for providing individualized and effective care to your patients.

In this blog post, you will:

• Know what a nursing care plan is

Purpose of Nursing Care Plans

• Know the 5 Steps to Writing a Nursing Care Plan
• Be provided with 3 Nursing care plan examples

Before we dive into this blog post I know how difficult learning everything in nursing school can be.  That is why I am offering you a free nursing mnemonic cheat sheet.  Just click below to get your copy!

Alright, lets begin!

What is a Nursing Care Plan

A Nursing Care Plan is the way a nurse documents and communicates the Nursing Process. Nursing care plans are one of the most common assignments in nursing school and can be a valuable resource in the clinical setting. They start when a patient is admitted and document all activities and changes in the patient’s condition. Using a care plan will encourage patient-centered care and make your nursing care more consistent. These plans are also a great communication tool among nurses, other healthcare professionals, patients, and their families. Nursing students learn to assess a patient, make a nursing diagnosis, create a plan, implement the plan, and evaluate the plan to ensure best practices and outcomes. This process teaches them to problem-solve and make critical decisions. A nursing care plan helps nurses organize their day, know when things need to be accomplished, and balance their workload.

The nursing care plan serves as a communication tool between healthcare professionals, ensuring a coordinated approach to patient care. It guides nurses in delivering evidence-based, patient-centered care, while also promoting continuity of care among different healthcare providers. Nursing care plans are essential in various healthcare settings, including hospitals, clinics, and long-term care facilities. They facilitate efficient and effective care delivery, enhance patient outcomes, and promote individualized care tailored to each patient's unique needs.

Nursing Care Plans are a written form of The Nursing Process. These plans ensure nurses deliver consistent, patient-centered, and holistic care. Each step in the nursing process is covered in the nursing care plan and helps nurses plan, implement, and evaluate nursing care.

• Assessment - The first step in delivering nursing care. It collects and analyzes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors data.
• Diagnosis  - Using the data, patient feedback, and clinical judgment to form nursing diagnoses. The diagnosis considers the patient’s signs, symptoms, pain, and the problems their condition has caused, such as anxiety, poor nutrition, conflict with family, and complications that may arise. The nursing diagnosis is the basis for the care plan. 
• Planning - Setting short-term and long-term goals based on the nurse’s assessment and diagnosis.  Ideally, with input from the patient. This is where you determine nursing interventions to meet these goals.
• Implementation  -  Implementing nursing care according to the care plan, based on the patient’s health conditions and the nursing diagnosis. This is where you will document the care the nurse performs. 
• Evaluation  - Monitoring and documenting the patient’s status and progress toward meeting the planned goals. This allows you to modify the care plan as needed. 

5 Steps to Writing a Nursing Care Plan

Writing a nursing care plan can seem overwhelming, but breaking it down into five simple steps can make the process more manageable. Here are five steps to help you write a nursing care plan:

Step 1 – Collect Information (Assess)

Gather relevant data about the patient's health status, medical history, current condition, and other pertinent factors. It involves systematically obtaining and organizing information to inform the development of the care plan.

• Head-to-toe-assessment
• Conversations with your patients and loved ones
• Observations (lab values, vital signs)
• Report (or your report sheet)
• Chart review notes
• Discussions with the healthcare team members

Step 2 – Analyze the Information (Diagnose & Prioritize)

Critically examining and interpreting the collected information and data to identify patterns, relationships, and underlying factors related to the patient's health condition. It involves synthesizing the information to gain a comprehensive understanding of the patient's needs and develop appropriate nursing diagnoses and interventions.

• Look at all information
• What are areas in which this patient has trouble and therefore needs to progress in?
• Think about the ways you could see the patient improving and how you would know they were improving
• Write down the general issues, how you’d help them progress in that area, and how you’d know they were progressing

Step 3 – Think About How (Plan, Implement, & Evaluate)

The process of critical thinking and considering various factors and possibilities when developing the plan. It involves evaluating different options, anticipating potential outcomes, and making informed decisions based on the patient's unique needs and circumstances.

• How did you know he was in pain? Did he tell you? Did you observe it? Was he getting pain medications?
• Write an S or an O next to them
• A recent surgery, trauma, or disease process?
• Write all of your reasons (again in layman's terms) under the problem(s) you’ve identified.
• What would you do to make this better? (Interventions)
• How would you know it got better? (Evaluation)

Step 4 – Translate

The process of converting the collected information, nursing diagnoses, goals, and interventions into clear and actionable language that can be easily understood and implemented by the healthcare team. 

• Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
• Look up the official terms for the problem(s) and write them down
• Look up outcomes and interventions that may align with what you wrote down

Step 5 – Transcribe

The process of accurately documenting the care plan in a written format. It involves transferring the information, including nursing diagnoses, goals, and interventions, into a standardized care plan document or electronic medical record.

• Get your nursing care plan template out
• Put the pieces together (problem + related to factor(s) + defining characteristics/”hows”)
• Use your S’s and O’s to place your subjective and objective data
• Write out your interventions and outcomes/evaluation

3 Nursing Care Plan Examples

Sometimes all you need are a few examples to help you learn how to do a difficult task and to get the brain juices flowing.  Here are 3 care plans that I personally wrote during nursing school.

Nursing Care Plan Example 1

Medical diagnosis: abdominal pain.

Pathophysiology of Abdominal Pain: 

Abdominal pain can be a minor issue that is easy to resolve or a medical emergency. Many different things can cause abdominal pain and their pathophysiology can differ widely. Abdominal pain can is classified as either acute or chronic. When a patient presents to the emergency department or outpatient environment with abdominal pain, it generally constitutes a lengthy workup to determine the cause and its pathophysiology. Additionally, abdominal pain can be referred pain, which can complicate the clinical picture even further.

Etiology of Abdominal Pain

Abdominal pain can be the result of pregnancy, ectopic pregnancy, trauma, a long list of gastric issues (gastroenteritis, constipation, diarrhea, irritable bowel syndrome, GERD, Chron’s disease, appendicitis, to name a few), hernias, allergic response, endometriosis, gallstones, severe menstrual cramps, hepatitis, miscarriage, and many more. Many disease processes result in abdominal pain, and some may present with abdominal pain even though it is not the typical clinical picture.

Desired Outcome

Cease painful stimuli, resolve the underlying cause, and minimize any subsequent damage.

Making an individualized assessment of abdominal pain begins by focusing on the available background information of the patient: health history, current health status, psychological state, and other relevant data.

Subjective Data: Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of abdominal pain, a patient might report feeling:

• Abdominal pain
• Decreased appetite
• Rebound tenderness
• Muscle tension
• Restlessness

Objective Data: Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of abdominal pain, a patient may present with:

• Constipation
• Electrolyte imbalances

A nursing diagnosis is a basis for establishing and carrying out a nursing care plan. After performing a proper assessment, formulate a nursing diagnosis based on problems associated with abdominal pain. This will be your clinical judgment about the patient’s health conditions or needs. Select the appropriate nursing diagnostic label from the NANDA-I list of approved nursing diagnostic statements that best identify with the patient’s signs and symptoms. One or more nursing diagnoses may be given.

Planning / Outcomes

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes. In the case of abdominal pain, a plan may include:

• Return to normal bowel movements
• Taking medications
• Receiving fluids
• Understanding their condition and treatment

Implementation

Implementations are actions and activities you will take to achieve the nursing plan goals. In the case of abdominal pain, an implementation may include:

• Encourage evacuation
• Encourage eating
• Administer medications as prescribed
• Provide fluids
• Educate the patient and family members

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions. In our abdominal pain example, an evaluation might include:

• The patient had 2 normal bowel movements
• The patient ate 3 meals
• Patient took medications
• Patient received fluids
• The patient understood information about their care

Nursing Care Plan Example 2

Medical diagnosis: infection.

Pathophysiology of Infection: 

An infection is a disease caused by microorganisms infecting tissues. 

Etiology of Infection

The organisms that can cause disease are very diverse that include viruses, bacteria, fungi, and parasites. You can acquire such infections by contaminated food/water, a bite, cut, or being in contact with someone with an infection.

Patient will remain free from infection and demonstrate proper hand hygiene

Subjective Data: Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of infection, a patient might report feeling:

• Muscle aches
• Sore throat

Objective Data: Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of infection, a patient may present with:

• Tachycardia
• Elevated WBC count
• Redness/swelling/heat/drainage from wound

Risk for Infection related to compromised skin integrity and invasive procedures.

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes. In the case of infection, a plan may include:

• The patient will maintain intact skin and mucous membranes.
• The patient will demonstrate understanding of infection prevention techniques.
• The patient's vital signs will remain within normal limits.
• The patient will report a decrease in signs and symptoms of infection.
• The patient will be free from healthcare-associated infections.

Implementations are actions and activities you will take to achieve the nursing plan goals. In the case of infection, an implementation may include:

• Assess the patient's skin integrity, paying close attention to areas at risk for infection such as surgical wounds, intravenous (IV) sites, and urinary catheter insertion sites.
• Implement proper hand hygiene techniques before and after providing care to the patient.
• Promote adequate hydration and provide a balanced diet to enhance the immune system.
• Educate the patient on proper wound care techniques, including keeping the wound clean, dry, and covered with appropriate dressings.
• Administer prescribed antibiotics and other medications as ordered.
• Monitor the patient's vital signs regularly and report any abnormalities or signs of infection promptly.

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions. In infection example, an evaluation might include:

• Assess the patient's skin regularly to ensure integrity and identify any signs of infection.
• Evaluate the patient's understanding and implementation of infection prevention techniques.
• Monitor vital signs and note any abnormalities.
• Assess the patient for any improvement in signs and symptoms of infection.
• Evaluate the patient's risk for healthcare-associated infections and implement appropriate preventive measures.

Nursing Care Plan Example 3

Medical diagnosis: fluid volume deficit.

Pathophysiology of Fluid Volume Deficit: 

Fluid Volume deficit (dehydration) is a state or condition where the fluid output exceeds the fluid intake. The body loses both water and electrolytes from the ECF in similar proportions. Common sources are the gastrointestinal tract, polyuria, and increased perspiration.

Common causes are decreased fluid intake, bleeding, diarrhea, diuresis, abnormal drainage, increased metabolic rate, movement of fluid into third space, and abnormal losses through the skin, GI tract, or kidneys.

Patient has normal vital signs. Demonstrates adequate lifestyle changes to avoid dehydration. Patient has normal urine output

Subjective Data: Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of Fluid Volume Deficit, a patient might report feeling:

• Weakness 
• Extreme thirst 

Objective Data: Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of Fluid Volume Deficit, a patient may present with:

• Alterations in mental state
• Weight loss
• Concentrated urine/decreased urine output
• Dry mucous membranes
• Weak pulse/tachycardia
• Decreased skin turgor
• Hypotension
• Postural hypotension
• Sunken eyes/cheeks

Diagnosis for Fluid Volume Deficit

Fluid Volume Deficit related to excessive fluid loss (e.g., vomiting, diarrhea, hemorrhage) as evidenced by decreased urine output, dry mucous membranes, and decreased skin turgor.

Planning / Outcomes for Fluid Volume Deficit

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes. In the case of Fluid Volume Deficit, a plan may include:

• The patient will maintain adequate fluid balance as evidenced by stable vital signs and improved hydration status.
• The patient will maintain optimal tissue perfusion.
• The patient will demonstrate understanding of fluid management and prevention of fluid volume deficit.

Implementation for Fluid Volume Deficit

Implementations are actions and activities you will take to achieve the nursing plan goals. In the case of Fluid Volume Deficit, an implementation may include:

• Assess and monitor vital signs, including blood pressure, heart rate, respiratory rate, and temperature, to identify signs of hypovolemia.
• Measure and record the patient's intake and output accurately to assess fluid balance.
• Monitor daily weights to track changes in fluid status.
• Encourage and assist the patient with oral fluid intake as tolerated, offering small, frequent sips of water or other fluids.
• Administer IV fluids as prescribed, ensuring accurate infusion rates and monitoring for any adverse reactions.
• Assess the patient's skin turgor, mucous membranes, and capillary refill time regularly to evaluate hydration status.
• Collaborate with the healthcare team to determine the underlying cause of fluid volume deficit and address it accordingly (e.g., treating the underlying infection or stopping excessive fluid losses).
• Monitor laboratory values, including electrolytes and hematocrit levels, and collaborate with the healthcare team to make any necessary adjustments to fluid therapy.

Evaluation for Fluid Volume Deficit

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions. In Fluid Volume Deficit example, an evaluation might include:

• Monitor and document the patient's vital signs and fluid intake and output regularly.
• Assess the patient's hydration status, including skin turgor, mucous membranes, and capillary refill time.
• Evaluate the patient's response to fluid therapy, including improvement in vital signs and hydration status.
• Assess the patient's understanding and implementation of fluid management strategies.
• Collaborate with the healthcare team to determine the need for further interventions or adjustments to the care plan.

Mastering the Art of Writing the Perfect Nursing Care Plan

Mastering the art of writing the perfect nursing care plan is crucial for delivering effective and individualized patient care.

By following the five essential steps -

• Collect Information (Assess)
• Analyze the Information (Diagnose & Prioritize)
• Think About How (Plan, Implement, & Evaluate)

You can create comprehensive care plans that address the unique needs of each patient.

Remember to utilize evidence-based practice, collaborate with the healthcare team, and continuously evaluate and modify the care plan as needed. With these strategies in place, you can confidently navigate the complexities of care planning, ensuring optimal patient outcomes and promoting the highest standards of nursing practice.

You Can Do This

Happy Nursing!

How To Master Nursing School (90 Days at a Time) | NURSING.com

Top 5 nursing student summer jobs + free tools for nursing school success, similar blog posts.

5 Steps to Writing a (kick ass) Nursing Care Plan (plus 5 examples) | NURSING.com

Diabetes Insipidus (DI) NCLEX Review for Nursing Students + Free Download

3 Need to knows about Disseminated Intravascular Coagulation (DIC) for the NCLEX

You are using an outdated browser. Please upgrade your browser to improve your experience.

Health & Nursing

Courses and certificates.

• Bachelor's Degrees
• View all Business Bachelor's Degrees
• Business Management – B.S. Business Administration
• Healthcare Administration – B.S.
• Human Resource Management – B.S. Business Administration
• Information Technology Management – B.S. Business Administration
• Marketing – B.S. Business Administration
• Accounting – B.S. Business Administration
• Finance – B.S.
• Supply Chain and Operations Management – B.S.
• Communications – B.S.
• User Experience Design – B.S.
• Accelerated Information Technology Bachelor's and Master's Degree (from the School of Technology)
• Health Information Management – B.S. (from the Leavitt School of Health)

Master's Degrees

• View all Business Master's Degrees
• Master of Business Administration (MBA)
• MBA Information Technology Management
• MBA Healthcare Management
• Management and Leadership – M.S.
• Accounting – M.S.
• Marketing – M.S.
• Human Resource Management – M.S.
• Master of Healthcare Administration (from the Leavitt School of Health)
• Data Analytics – M.S. (from the School of Technology)
• Information Technology Management – M.S. (from the School of Technology)
• Education Technology and Instructional Design – M.Ed. (from the School of Education)

Certificates

• Supply Chain
• Accounting Fundamentals
• Digital Marketing and E-Commerce
• View all Business Degrees

Bachelor's Preparing For Licensure

• View all Education Bachelor's Degrees
• Elementary Education – B.A.
• Special Education and Elementary Education (Dual Licensure) – B.A.
• Special Education (Mild-to-Moderate) – B.A.
• Mathematics Education (Middle Grades) – B.S.
• Mathematics Education (Secondary)– B.S.
• Science Education (Middle Grades) – B.S.
• Science Education (Secondary Chemistry) – B.S.
• Science Education (Secondary Physics) – B.S.
• Science Education (Secondary Biological Sciences) – B.S.
• Science Education (Secondary Earth Science)– B.S.
• View all Education Degrees

Bachelor of Arts in Education Degrees

• Educational Studies – B.A.

Master of Science in Education Degrees

• View all Education Master's Degrees
• Curriculum and Instruction – M.S.
• Educational Leadership – M.S.
• Education Technology and Instructional Design – M.Ed.

Master's Preparing for Licensure

• Teaching, Elementary Education – M.A.
• Teaching, English Education (Secondary) – M.A.
• Teaching, Mathematics Education (Middle Grades) – M.A.
• Teaching, Mathematics Education (Secondary) – M.A.
• Teaching, Science Education (Secondary) – M.A.
• Teaching, Special Education (K-12) – M.A.

Licensure Information

• State Teaching Licensure Information

Master's Degrees for Teachers

• Mathematics Education (K-6) – M.A.
• Mathematics Education (Middle Grade) – M.A.
• Mathematics Education (Secondary) – M.A.
• English Language Learning (PreK-12) – M.A.
• Endorsement Preparation Program, English Language Learning (PreK-12)
• Science Education (Middle Grades) – M.A.
• Science Education (Secondary Chemistry) – M.A.
• Science Education (Secondary Physics) – M.A.
• Science Education (Secondary Biological Sciences) – M.A.
• Science Education (Secondary Earth Science)– M.A.
• View all Technology Bachelor's Degrees
• Cloud Computing – B.S.
• Computer Science – B.S.
• Cybersecurity and Information Assurance – B.S.
• Data Analytics – B.S.
• Information Technology – B.S.
• Network Engineering and Security – B.S.
• Software Engineering – B.S.
• Accelerated Information Technology Bachelor's and Master's Degree
• Information Technology Management – B.S. Business Administration (from the School of Business)
• User Experience Design – B.S. (from the School of Business)
• View all Technology Master's Degrees
• Cybersecurity and Information Assurance – M.S.
• Data Analytics – M.S.
• Information Technology Management – M.S.
• MBA Information Technology Management (from the School of Business)
• Full Stack Engineering
• Web Application Deployment and Support
• Front End Web Development
• Back End Web Development

3rd Party Certifications

• IT Certifications Included in WGU Degrees
• View all Technology Degrees
• View all Health & Nursing Bachelor's Degrees
• Nursing (RN-to-BSN online) – B.S.
• Nursing (Prelicensure) – B.S. (Available in select states)
• Health Information Management – B.S.
• Health and Human Services – B.S.
• Psychology – B.S.
• Health Science – B.S.
• Public Health – B.S.
• Healthcare Administration – B.S. (from the School of Business)
• View all Nursing Post-Master's Certificates
• Nursing Education—Post-Master's Certificate
• Nursing Leadership and Management—Post-Master's Certificate
• Family Nurse Practitioner—Post-Master's Certificate
• Psychiatric Mental Health Nurse Practitioner —Post-Master's Certificate
• View all Health & Nursing Degrees
• View all Nursing & Health Master's Degrees
• Nursing – Education (BSN-to-MSN Program) – M.S.
• Nursing – Leadership and Management (BSN-to-MSN Program) – M.S.
• Nursing – Nursing Informatics (BSN-to-MSN Program) – M.S.
• Nursing – Family Nurse Practitioner (BSN-to-MSN Program) – M.S. (Available in select states)
• Nursing – Psychiatric Mental Health Nurse Practitioner (BSN-to-MSN Program) – M.S. (Available in select states)
• Nursing – Education (RN-to-MSN Program) – M.S.
• Nursing – Leadership and Management (RN-to-MSN Program) – M.S.
• Nursing – Nursing Informatics (RN-to-MSN Program) – M.S.
• Master of Healthcare Administration
• Master of Public Health
• MBA Healthcare Management (from the School of Business)
• Business Leadership (with the School of Business)
• Supply Chain (with the School of Business)
• Accounting Fundamentals (with the School of Business)
• Digital Marketing and E-Commerce (with the School of Business)
• Back End Web Development (with the School of Technology)
• Front End Web Development (with the School of Technology)
• Web Application Deployment and Support (with the School of Technology)
• Full Stack Engineering (with the School of Technology)
• Single Courses
• Course Bundles

Apply for Admission

Admission requirements.

• New Students
• WGU Returning Graduates
• WGU Readmission
• Enrollment Checklist
• Accessibility
• Accommodation Request
• School of Education Admission Requirements
• School of Business Admission Requirements
• School of Technology Admission Requirements
• Leavitt School of Health Admission Requirements

Additional Requirements

• Computer Requirements
• No Standardized Testing
• Clinical and Student Teaching Information

Transferring

• FAQs about Transferring
• Transfer to WGU
• Transferrable Certifications
• Request WGU Transcripts
• International Transfer Credit
• Tuition and Fees
• Financial Aid
• Scholarships

Other Ways to Pay for School

• Tuition—School of Business
• Tuition—School of Education
• Tuition—School of Technology
• Tuition—Leavitt School of Health
• Your Financial Obligations
• Tuition Comparison
• Applying for Financial Aid
• State Grants
• Consumer Information Guide
• Responsible Borrowing Initiative
• Higher Education Relief Fund

FAFSA Support

• Net Price Calculator
• FAFSA Simplification
• See All Scholarships
• Military Scholarships
• State Scholarships
• Scholarship FAQs

Payment Options

• Payment Plans
• Corporate Reimbursement
• Current Student Hardship Assistance
• Military Tuition Assistance

WGU Experience

• How You'll Learn
• Scheduling/Assessments
• Accreditation
• Student Support/Faculty
• Military Students
• Part-Time Options
• Virtual Military Education Resource Center
• Student Outcomes
• Return on Investment
• Students and Gradutes
• Career Growth
• Student Resources
• Communities
• Testimonials
• Career Guides
• Skills Guides
• Online Degrees
• All Degrees
• Explore Your Options

Admissions & Transfers

• Admissions Overview

Tuition & Financial Aid

Student Success

• Prospective Students
• Current Students
• Military and Veterans
• Commencement
• Careers at WGU
• Advancement & Giving
• Partnering with WGU

Nursing Care Plans: An Introduction

• See More Tags

What is a Nursing Care Plan?

A nursing care plan is a road map for the care of a patient and a necessary tool in following the nursing process. Understanding nursing care plans is an important part of any nursing school curriculum and definitely something you’ll need to know as a nursing student. 

In this guide, you’ll learn how to write and use a nursing care plan and why they’re important for maintaining quality patient care.

Why are Care Plans Important?

Care plans play a vital role in the treatment of a patient. They clearly define guidelines along with the nurse’s role in patient care and help them create and achieve a solid plan of action. This equips nurses to provide focused care—without overlooking important steps.

Nursing care plans also promote:

Collaboration

• A well-documented care plan ensures the patient’s entire care team (doctors, nurses, etc.) can access the same information, give input, and join forces to provide the best care possible.
• Care plans help nurses uphold the nursing code of ethics and provide a record that they did so in case of lawsuits or accusations that they failed to adhere to care standards.
• A care plan is a communication tool for patient care between nurses. When nurses change shifts they’re able to reference the patient’s care plan to ensure the same quality care and interventions are being executed.

Without nursing care plans, nursing staff might have to rely on verbal communication and patient information could become more easily scattered or lost, all of which could result in improper patient care .

How to Write a Nursing Care Plan

Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation.

Assess the patient.

The first step to writing a care plan is performing a patient assessment. This includes reviewing your patient’s medical history, diagnosis, lab values, and medications. This step is critical to creating an effective and accurate care plan for either short term or long term care.

Make a diagnosis.

Nursing diagnoses differs from a medical diagnosis in that it’s based on the patient’s response to an illness, rather than the illness itself. Simply put, a nursing diagnosis is focused on patient care rather than treatment.

According to NANDA (North American Nursing Diagnosis Association), a good nursing care plan should not only list each diagnosis but define it as well. For example, acid reflux should be described as: "Ineffective airway clearance related to gastroesophageal reflux as evidenced by retching, upper airway congestion, and persistent coughing.”

Set goals and outcomes.

Once you’ve completed an assessment and diagnosis, it’s time to write down goals and a desired health care outcomes for your patient. These describe what you hope to achieve in the short- and long-term future, provide direction for planning interventions, and serve as criteria for evaluating progress. Goals are documented in the patient’s care plan so that other nurses and health professionals caring for the patient have access to it.

Determine nursing interventions.

At this point in the care plan, you’ll list all planned nursing interventions and document any that you’ve performed. You’ll write down things such as client responses to care, pain scale responses, medications given and their dosages, vital signs, etc. This communicates what nursing orders were implemented, what still needs to be done, and if the patient is ready to be discharged.

Evaluate the plan.

Evaluation is necessary in a patient care plan to determine whether to continue, adjust, or terminate the plan of care. It measures the degree to which goals and outcomes are achieved and provides evidence for what factors positively or negatively impacted those goals.

How to Use a Nursing Care Plan

Registered nurses and nurse practitioners use these plans in the nursing process as a road map for providing care. They’re also a tool to help nurses think critically and holistically to support the patient’s needs—physically, socially, spiritually, and psychosocially. Only RNs can develop the care plan and make changes, although LPNs can contribute suggestions.

A nursing care plan begins as soon as a patient is admitted and is updated frequently as their condition changes or after an evaluation. It’s an ongoing process that requires detailed, accurate documentation that strictly adheres to the nursing code of ethics , as well as HIPAA rules and regulations .

Knowing how to write and implement a nursing care plan is one essential skill you’ll need as a nurse or nurse practitioner . With a degree in nursing , you’ll gain this valuable experience—and the tools to provide the best patient care possible.

Ready to Start Your Journey?

HEALTH & NURSING

Recommended Articles

Take a look at other articles from WGU. Our articles feature information on a wide variety of subjects, written with the help of subject matter experts and researchers who are well-versed in their industries. This allows us to provide articles with interesting, relevant, and accurate information. 

{{item.date}}

{{item.preTitleTag}}

{{item.title}}

The university, for students.

• Student Portal
• Alumni Services

Most Visited Links

• Business Programs
• Student Experience
• Diversity, Equity, and Inclusion
• Student Communities

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 relationships 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

Labor and Delivery: Nursing Diagnoses, Care Plans, Assessment & Interventions

Labor is a series of contractions that help with dilation and effacement of the cervix to allow the fetus to move through the birth canal and out of the vagina. Labor usually begins around the EDD (expected date of delivery), but no one can predict exactly when it will start.

In this article:

• Stages of Labor
• Nursing Process
• Review of Health History
• Physical Assessment
• Diagnostic Procedures
• Nursing Interventions
• Risk for Decreased Cardiac Output
• Risk for Imbalanced Fluid Volume
• Risk for Infection

Labor can be broken down into three stages:

Stage 1: Early and active labor. This is the longest stage of labor. Contractions will progress until they are five minutes apart, which is when the patient should present to the hospital. The cervix will begin to dilate to 4-6 centimeters. In active labor, contractions become stronger and occur more frequently. Patients may feel the urge to push as the baby moves farther into the birth canal.

Stage 2: Delivery of the baby. Once the cervix is dilated to 10 centimeters, it is time to push. Contractions are more frequent, and the mother is instructed to push during them. This stage ends with the delivery of the baby.

Stage 3: Delivery of the placenta. Once the baby is delivered, the placenta will pass through the uterus and finally out of the vagina.

Depending on the circumstances, babies are delivered via vaginal delivery or Cesarean section . The most common and preferred method is vaginally because it carries the lowest risk for complications and results in a faster recovery.

A C-section is done by an obstetrician making surgical incisions in the abdomen and uterus. It can be planned in advance or may occur during labor if an emergency arises, such as fetal distress, placental abruption, umbilical cord prolapse, or excessive bleeding.

Labor and delivery nurses take care of women and their babies before, during, and after the delivery. They serve as the connection between the patient and the doctor. The nurse is a source of support for the mother and provides education, comfort measures, and updates about the progress of their labor, and about any possible interventions that may be needed further on. During C-section delivery, the nurse may also scrub in to assist in the surgery.

Nursing Assessment

The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to labor and delivery.

1. Review the patient’s prenatal care. The patient’s prenatal care should be reviewed, together with confirmation of the expected delivery date, as part of the initial assessment of labor.

2. Obtain a thorough history. Ask the patient about the fetus’ movements, the frequency and timing of contractions, the status of the amniotic membranes, and the presence or absence of vaginal bleeding. The nurse should also review the mother’s medical, surgical, and obstetric history, along with recent lab values and imaging data.

3. Ensure the contractions are true. True contractions must be distinguished from Braxton-Hicks contractions, which are irregular and not as severe as true labor contractions. Braxton-Hicks contractions commonly subside when the patient walks or changes activity.

1. Assess for signs of labor. Signs of labor vary for every patient, but the most common ones are:

• Progressive, regular contractions
• Rupture of the amniotic sac or “water breaking”
• Bloody show or blood-tinged mucus
• Pain in the abdomen and lower back

2. Perform Leopold’s maneuver. Leopold’s maneuvers determine the position of the fetus:

• The first maneuver involves gentle palpation to identify which fetal part is present in the fundus.
• The second maneuver involves separating the fetal spine from its limbs to determine the position of the fetal back.
• The third maneuver confirms fetal presentation and enables the measurement of fetal weight and amniotic fluid content.
• The fourth maneuver involves checking which fetal presenting part is engaged in the mother’s pelvis.

Abnormal presentations such as breech, brow, face, or shoulder presentation can cause complications and require manipulation. 

3. Monitor vital signs. High blood pressure could indicate preeclampsia and eclampsia, which can be dangerous for the mother and fetus during labor and delivery.

4. Perform a pelvic exam. Check the cervix’s opening for dilation and effacement (thinning of the cervix). The visual confirmation of amniotic fluid in the cervix is done during a sterile speculum examination if membrane rupture is suspected. 

5. Monitor the pattern of contractions. Contractions become stronger and more frequent as labor progresses. They may be two to five minutes apart and last for 60-90 seconds during the second stage of labor. The mother is instructed to push during a contraction and rest between. 

6. Determine the fetal station. The fetal station determines where the lowest part of the baby is in relation to the mother’s pelvis and is given a number -5 to +5 cm. A station of -5 means the baby’s head is not yet within the birth canal, while a station of +5 means the baby has descended into the vaginal opening. A station of 0 means the baby’s head is “engaged” within the mother’s ischial spines and occurs about two weeks before labor.

7. Determine the patient’s level of pain. Utilize the numeric pain scale to determine the patient’s pain. The patient’s pain level is assessed frequently to determine a need for interventions.

1. Assist with pelvic evaluation. A clinical examination (clinical pelvimetry) and radiographic methods (CT or MRI) can be used to evaluate the shape and dimensions of the maternal pelvis to predict if complications may occur with delivery. This may be completed during a prenatal visit or at the time of labor.

2. Obtain samples for routine lab tests. Routine laboratory tests done for a patient in labor include:

• Complete blood cell (CBC) count
• Blood typing and screening

3. Monitor uterine contractions. External tocometer monitoring should begin as soon as the mother enters the labor and delivery area to determine the onset and duration of uterine contractions.

4. Assess the fetal heart tones and rate. Use a Doppler device, external belt, or internal electrode to assess fetal heart tones and heart rate.

5. Assist with bedside ultrasound. Bedside ultrasonography may be performed to confirm the fetal presentation and position of the fetal presenting part. Ultrasonography can identify potential complications that may require C-section delivery.

Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for labor and delivery.

Manage Patient and Fetus During Labor

1. Explain the need for frequent cervical exams. Cervical exams monitor labor progress through cervical dilation and effacement. Unless problems necessitate more frequent assessments, sterile cervical exams are typically performed every 2 to 3 hours. A higher risk of infection is linked to more frequent cervical checks, particularly when there has been a membrane rupture. 

2. Encourage ambulation and changes in position. Women should be free to move around and change positions as they like. It helps the fetus descend further into the pelvis and relieves pain.

3. Initiate an IV line. An intravenous catheter is often established to provide medication or fluids to the patient.

4. Let the patient eat. There should be no restriction on oral intake. Intravenous fluids should be provided to help restore losses if the patient goes without food or liquid for an extended period. 

5. Manage the labor pain. For qualified candidates, analgesia is provided through intravenous opioids, inhaled nitrous oxide, and epidural blocks. Nonpharmacological methods of pain relief include massage, breathing, and movement.

6. Institute comfort measures. Comfort measures that calm and relax the mother during labor may reduce discomfort and pain. The nurse can recommend the following:

• Create a calming atmosphere with warm lighting, quiet surroundings, soothing music, and privacy.
• Advise the patient to try walking, slow dancing with a partner, pelvic rocking, comfortable pillow placement, sitting and swaying on a birth ball (a large physiotherapy ball), and rocking in a rocking chair to increase physical comfort.
• Encourage massage, acupressure, or counterpressure to the lower back.
• Apply heat through a heated blanket/pad or shower/bath.
• Apply a cold compress to the lower back and a cool towel to the face.

7. Prepare for amniotomy if needed. Amniotomy is the artificial rupture of membranes (AROM) that helps induce and shorten labor. Amniotomy is not always necessary or helpful. 

8. Administer oxytocin. Oxytocin may be administered intravenously to stimulate contractions if labor is stalled.

9. Prevent complications. Any stage of labor can experience complications that lead to maternal or fetal injuries or even death. 

• Women may experience arrest of labor during the first stage , necessitating a Cesarean section.
• Asphyxiation
• Brain damage
• Low blood pH (acidemia)
• Shoulder lodged in the birth canal (shoulder dystocia)
• Bone fractures
• Fetal injury
• Nerve palsies
• Pooling of blood (hematoma) in the scalp 
• Uterine rupture
• Vaginal laceration
• Cervical laceration
• Uterine hemorrhage
• Amniotic fluid embolism
• Cord avulsion
• Retained placenta
• Incomplete placenta evacuation 

Monitor in the Postpartum Period

1. Control the pain. A C-section delivery may require pain relief in the form of NSAIDs or narcotic analgesics. Mothers may experience “after pains” following delivery, caused by contractions of the uterus as it relaxes and contracts back to its normal size. A vaginal delivery will result in soreness, and if an episiotomy was required or if lacerations occurred, discomfort is expected. The nurse can offer the following remedies:

• Sitting on a donut pillow
• A warm sitz bath
• Placing an ice pack or chilled sanitary pad on the perineum
• Acetaminophen or ibuprofen to reduce inflammation

2. Monitor vaginal discharge. Lochia is the vaginal discharge that occurs after childbirth. It is made up of blood, mucus, and tissues and has three stages:

• Lochia rubra: dark red in color, lasting 4 days
• Lochia serosa: color changes to pink, lasting 10 days
• Lochia alba: lochia is white or yellow, lasting up to 2 weeks

During the first 24 hours after childbirth, blood flow may be heavy, but should not soak more than one maternity pad every few hours. If the mother is soaking a maternity pad every hour or passing large clots, this is abnormal and requires intervention.

3. Discuss preventing constipation . Having a bowel movement for the first few times after childbirth may be painful, and the mother is at risk for hemorrhoids from straining if constipated. The nurse can recommend the following strategies:

• Begin a stool softener or laxative to prevent constipation
• Eat high-fiber foods and drink plenty of water
• Use an over-the-counter hemorrhoid cream to relieve discomfort
• Use pads containing witch hazel to soothe the perineum
• Soak the perineum and anal area in a sitz bath several times per day

4. Advise the patient to practice proper hygiene. Demonstrate appropriate perineal care and effective handwashing methods. After childbirth, cleansing the perineum from front to back will help reduce the risk of introducing microorganisms into perineal lacerations. After delivery, keeping the area clean will help the wound heal more quickly.

5. Recognize changes in mood and emotions. Childbirth is an emotional experience, and the mother may experience a range of emotions, such as mood swings, anxiety, insomnia , and crying spells. Some emotional changes may be related to fluctuations in hormones. Still, if symptoms persist or are accompanied by loss of appetite, lack of joy in life, or withdrawal from the newborn, this may signal postpartum depression that necessitates intervention.

6. Promote breastfeeding. As soon as the patient is ready, begin nursing. Consult a lactation consultant or nurse to educate the mother on how to support the infant and position herself comfortably during breastfeeding . Educate on methods to reduce breast engorgement and prevent cracked nipples and breast discomfort.

7. Remind of postpartum checkups. The first postpartum checkup should occur within several weeks after delivery and may include several visits to monitor the mother’s mood, discuss contraception plans, and ensure healing from childbirth.

Nursing Care Plans

Once the nurse identifies nursing diagnoses for labor and delivery, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for labor and delivery.

Labor and delivery is an extremely painful process, and the duration and intensity vary for each individual. The pain is caused by muscle contractions in the uterus and immense pressure on the cervix. It will present itself as intense cramps in multiple parts of the body, such as the abdomen, groin, and back.

Nursing Diagnosis: Acute Pain

Related to:

• Muscle contractions
• Tissue trauma

As evidenced by:

• Restlessness
• Moaning, crying, wincing
• Verbalization of pain
• Facial mask of pain
• Diaphoresis
• Tachycardia and tachypnea

Expected outcomes:

• Patient will verbalize a decrease in pain.
• Patient will show signs of being at ease and comfort, as evidenced by resting and breathing even and unlabored.
• Patient will demonstrate and utilize practices that will help reduce the pain, such as relaxation and breathing techniques and changes in body positioning.

Assessment:

1. Assess the patient’s level of pain using the numeric pain scale. Pain is always subjective. Finding out how much pain the patient is experiencing is important to drive further interventions.

2. Screen pain along with assessing vital signs. Pain is often considered the fifth vital sign. In addition to this, blood pressure, pulse, and respiratory rates can elevate when experiencing pain.

Interventions:

1. Establish a rapport with the patient and their significant other. Entertaining any questions they may have will reduce barriers in communication, ultimately easing any fears and promoting trust and relaxation.

2. Instruct the patient on breathing techniques. Breathing can help distract from pain. The nurse can instruct on breathing techniques such as belly breathing or pant-pant-blow breathing through contractions.

3. Discuss pain relief options. The mother should be in charge of her labor plan. The nurse can discuss and explain options for pain relief and help the mother decide what is best for them.

4. Assist the patient in positioning. Adjusting the body’s positioning will help limit fatigue and enhance circulation. Allow the mother to decide which positions relieve pain, such as side-lying, leaning, or on all fours.

5. Provide comfort measures. Back rubs, pillows for better positioning, and ice cubes can provide short-term relief.

6. Administer analgesics if ordered. An epidural can be placed to block pain below the waist. The nurse assists the anesthesiologist with positioning and preparing the site for epidural insertion in the lower back.

Anxiety is normal and can begin long before labor and delivery. Especially with first-time mothers, childbearing comes with the fear of not knowing how the delivery will turn out and worries regarding the baby’s health and the pain of childbirth. The possible use of epidurals and the need for a C-section also contribute to the fear.

Nursing Diagnosis: Anxiety

• Perceived threat to baby
• Fear of unexpected outcomes
• Surgical intervention (C-section)
• Threat to health
• Fear of pain
• Increased tension
• Feelings of inadequacy
• Expression of concerns
• Alterations in vital signs
• Patient will verbalize ease of worries and stress .
• Patient will express feelings of concern and anxiety.
• Patient will utilize support systems effectively.

1. Assess psychological and emotional state. Emotions related to anxiety and uncertainty can affect the labor and delivery process and interfere with the patient’s willingness to cooperate.

2. Assess the patient’s specific concerns. Inquiring about the patient’s causes of anxiety can open up a dialogue that allows the nurse to potentially clarify and assuage feelings of fear or the unknown.

1. Acknowledge the patient’s feelings and verbalizations that may indicate guilt. Knowing how the patient feels towards the process will help gauge how they understand why interventions can sometimes be required during labor and delivery and that these choices are available because they may be medically necessary and not because they are lacking personally.

2. Acknowledge and include their support system. Keeping the significant other/s involved during the process, as well as praising them for any progress, will help establish rapport and trust, leading to a more relaxed environment during childbirth.

3. Maintain a calm demeanor, giving clear and concise explanations. During emergency deliveries, anxiety may occur due to the process not meeting their expectations. The nurse should remain calm and assertive to maintain control of the situation.

4. Encourage relaxation techniques. To keep the abdominal wall from becoming tense, the patient needs to be instructed in proper relaxation techniques such as deep-breathing exercises, effleurage (light, rhythmic, circular strokes on the abdomen), and gentle massages of the shoulders and limbs. This will allow the uterus to rise with contractions without pressing against the hard abdominal wall.

5. Provide a calm environment. Labor can be a long process. When appropriate, keep lighting dim and noises and interruptions to a minimum to allow for rest.

During labor, when the uterus contracts, there is a notable increase in cardiac output as it increases stroke volume and heart rate. However, complications of labor and delivery like hemorrhage, hypertension, and fluid imbalances can increase the risk of patients developing decreased cardiac output.

Nursing Diagnosis: Risk for Decreased Cardiac Output

• Complications from labor and delivery
• Uterine atony
• Dehydration
• Fluid and electrolyte imbalance
• Decreased fluid volume
• Hypertension
• Hypotension
• Cardiac conditions
• Childbirth process

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

• Patient will remain free from any signs of decreased cardiac output, like arrhythmias, shortness of breath , and alterations in vital signs.
• The fetal heart rate will remain within normal limits.

1. Assess the patient’s vital signs regularly and in between contractions. Blood pressure naturally increases during the intrapartum phase. Cardiac output will be negatively affected when venous return is reduced due to uterine pressure on the inferior vena cava, dehydration caused by decreased circulating blood volume, or bleeding.

2. Assess fetal heart rate during labor and delivery. The fetal status will be affected if the patient develops decreased cardiac output, causing uteroplacental insufficiency and reduced oxygen delivery to the fetus.

1. Instruct the patient to lie in the left lateral side-lying position. Lateral positioning on the left side increases stroke volume and venous return, ensuring adequate blood circulation throughout the body.

2. Monitor for any signs of bleeding. Pregnant women are prone to bleeding during labor and delivery. Heavy vaginal bleeding and a significant decrease in blood pressure must be monitored during labor and delivery, as this can further complicate cardiac output.

3. Administer supplemental oxygenation as needed. Oxygenation may be compromised in patients who are in labor. Providing supplemental oxygenation can help ensure adequate circulating oxygen and uteroplacental perfusion.

4. Monitor vital signs after anesthesia. Spinal anesthesia is used in the event of C-section delivery and carries the risk of cardiovascular effects like hypotension with compensatory tachycardia and increased stroke volume.

5. Perform fetal heart monitoring. The fetal heart rate is monitored during labor and delivery and should be between 110-160 beats per minute. Late decelerations are caused by decreased blood flow to the placenta from maternal dehydration, hypotension from epidural, anemia , and hypoxia.

Labor and delivery predispose pregnant women to a risk for imbalanced fluid volume due to blood loss, dehydration, and nausea and vomiting.

Nursing Diagnosis: Risk for Imbalanced Fluid Volume

• Altered fluid intake
• Nausea and vomiting
• Patient will display urine output and lab values within normal limits.
• Patient will maintain pulse rate, temperature, blood pressure, respiratory rate, and oxygen saturation within normal parameters.

1. Assess the medical history and factors that predispose the patient to fluid imbalance. A thorough medical history can help determine if the patient is at risk for hemorrhage during labor and delivery. Patients with high-risk pregnancies due to complications like placenta previa or preeclampsia have an increased risk of bleeding and dehydration during labor and delivery.

2. Monitor the patient’s laboratory values. A CBC (complete blood count) may be assessed prior to delivery and monitored closely for changes in hemoglobin and hematocrit that signal blood loss.

3. Assess the patient’s vital signs. Alterations in vital signs are indicators of fluid and electrolyte imbalance. A bounding pulse and elevated blood pressure can indicate fluid volume excess, while a decreased blood pressure, weak thready pulse, and tachycardia can indicate fluid volume deficit.

1. Monitor the patient’s blood pressure and pulse during oxytocin infusion. Oxytocin infusion is typically indicated to stimulate contractions when labor is not progressing. Water intoxication can occur during oxytocin infusion as this medication reduces urine excretion and promotes fluid retention.

2. Encourage fluid intake. Eating and drinking are no longer prohibited during labor. The patient can eat and drink freely unless directed otherwise.

3. Administer IV fluids as indicated. IV fluids may be necessary if the patient is experiencing nausea or vomiting or is unable or uninterested in consuming fluids.

4. Monitor intake and output. Patients undergoing C-section delivery will have a urinary catheter inserted and kept in place for at least 8 hours after delivery. Closely monitor intake and output for imbalances.

The risk of infection increases due to the ability of some pathogens to invade after the rupture of amniotic membranes. Puerperal sepsis is an infection in the genital tract that can occur after giving birth and spread throughout the body.

Nursing Diagnosis: Risk for Infection

• Repetitive vaginal examinations
• Rupture of amniotic membranes
• Fecal contamination
• Umbilical cord prolapse
• Patient will verbalize signs and symptoms of infection to notify the nurse and/or provider of.
• Patient will demonstrate keeping their environment clean, safe, and aseptic.
• Patient will show no signs of infection.

1. Assess vaginal secretions and amniotic fluid. If the secretions are tested using Nitrazine paper, an alkaline reaction (blue) will confirm the presence of amniotic fluid. The color, odor, amount, and character should be recorded. Discoloration and foul odor will indicate possible infection as normal fluids should appear clear, with some specks of vernix (protective layer on baby’s skin) and lanugo (hair covering the baby’s body).

2. Monitor and record fetal heart rate. A rate greater than 160 beats per minute (fetal tachycardia) may indicate infection. Poor oxygenation may also occur, especially during abnormal labor.

3. Monitor vital signs and white blood cell count. An elevation of WBC count and abnormal vital signs can indicate infection (maternal temperatures of 38℃/100°F or higher and a WBC count of more than 18,000-20,000/mm³). There is an increased risk for intra-amniotic infection (chorioamnionitis) within 4 hours of membrane rupture.

1. Limit vaginal examinations. Repeated vaginal examinations increase the risk of introducing pathogens into the vagina and birth canal.

3. Utilize aseptic technique during invasive procedures. The use of aseptic technique will help in preventing and limiting the growth of bacteria, such as during IV or urinary catheter insertions.

4. Demonstrate proper perineal care and good handwashing techniques. Proper handwashing reduces the risk of infection. Proper perineal hygiene, such as wiping from front to back after giving birth, will help lessen the possibility of introducing pathogens into perineal lacerations. Keeping the site clean after birth will also aid in faster wound recovery .

5. Administer antibiotics as prescribed. The administration of antibiotics during labor is controversial as the medication may affect the baby. Still, when needed, it may protect against infection, such as in case of prolonged rupture of membranes.

6. Administer oxytocin as prescribed. Oxytocin is a natural hormone used to induce labor by causing the uterus to contract. The longer it takes for the baby to come out, the more susceptible the mother and the baby are to infections.

• Cleveland Clinic. Types of Delivery. https://my.clevelandclinic.org/health/articles/9675-pregnancy-types-of-delivery . Accessed on Nov. 27, 2022
• Johns Hopkins Medicine. Labor. https://www.hopkinsmedicine.org/health/wellness-and-prevention/labor . Accessed Nov. 26, 2022
• Healthwise Staff. (2022, February 23). Breathing techniques for childbirth. MyHealth.Alberta.ca. Retrieved May 2023, from https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=tn7421
• Hutchison, J., Mahdy, H., Hutchison, J. (2022). Stages of Labor. StatPearls Publishing LLC.
• Hutchison, J., Mahdy, H., & Hutchison, J. (2023, January 23). Stages of labor – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved May 2023, from https://www.ncbi.nlm.nih.gov/books/NBK544290/
• Mayo Clinic. Labor induction. https://www.mayoclinic.org/tests-procedures/labor-induction/about/pac-20385141 . Accessed Nov. 26, 2022
• Mayo Clinic. (2022, January 13). Stages of labor and birth: Baby, it’s time! Retrieved May 2023, from https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/stages-of-labor/art-20046545
• Milton, S. H. (2021, April 3). Normal labor and delivery: Practice essentials, definition, stages of labor and epidemiology. Diseases & Conditions – Medscape Reference. Retrieved May 2023, from https://emedicine.medscape.com/article/260036-overview#a7
• National Partnership for Women & Families. (2023, April 29). Comfort measures for labor pain relief. Retrieved May 2023, from https://nationalpartnership.org/childbirthconnection/giving-birth/labor-pain/comfort-relief/

Newly Launched - AI Presentation Maker

• Customer Favourites

AI PPT Maker

Powerpoint Templates

Icon Bundle

Kpi Dashboard

Professional

Business Plans

Swot Analysis

Gantt Chart

Business Proposal

Marketing Plan

Project Management

Business Case

Business Model

Cyber Security

Business PPT

Digital Marketing

Digital Transformation

Human Resources

Product Management

Artificial Intelligence

Company Profile

Acknowledgement PPT

PPT Presentation

Reports Brochures

One Page Pitch

Interview PPT

All Categories

• You're currently reading page 1

Stages // require(['jquery'], function ($) { $(document).ready(function () { //removes paginator if items are less than selected items per page var paginator = $("#limiter :selected").text(); var itemsPerPage = parseInt(paginator); var itemsCount = $(".products.list.items.product-items.sli_container").children().length; if (itemsCount ? ’Stages’ here means the number of divisions or graphic elements in the slide. For example, if you want a 4 piece puzzle slide, you can search for the word ‘puzzles’ and then select 4 ‘Stages’ here. We have categorized all our content according to the number of ‘Stages’ to make it easier for you to refine the results.

Category // require(['jquery'], function ($) { $(document).ready(function () { //removes paginator if items are less than selected items per page var paginator = $("#limiter :selected").text(); var itemsperpage = parseint(paginator); var itemscount = $(".products.list.items.product-items.sli_container").children().length; if (itemscount.

• Brochures Layout (2)
• Business Plan Word (12)
• Business Plans (9)
• Business Slides (4691)
• Circular (196)

• Open access
• Published: 12 August 2024

How is diagnostic uncertainty communicated and managed in real world primary care settings?

• Jessica Russell   ORCID: orcid.org/0000-0003-3194-412X 1 ,
• Laura Boswell   ORCID: orcid.org/0000-0001-9611-7091 2 ,
• Athena Ip   ORCID: orcid.org/0000-0002-8574-2569 2 ,
• Jenny Harris   ORCID: orcid.org/0000-0001-8933-117X 2 ,
• Hardeep Singh   ORCID: orcid.org/0000-0002-4419-8974 3 ,
• Ashley N. D. Meyer   ORCID: orcid.org/0000-0001-7993-8584 3 ,
• Traber D. Giardina   ORCID: orcid.org/0000-0002-9184-6524 3 ,
• Afsana Bhuiya   ORCID: orcid.org/0000-0002-2165-9192 4 ,
• Katriina L. Whitaker   ORCID: orcid.org/0000-0002-0947-1840 2 &
• Georgia B. Black   ORCID: orcid.org/0000-0003-2676-5071 1  

BMC Primary Care volume  25 , Article number:  296 ( 2024 ) Cite this article

Metrics details

Managing diagnostic uncertainty is a major challenge in primary care due to factors such as the absence of definitive tests, variable symptom presentations and disease evolution. Maintaining patient trust during a period of investigative uncertainty, whilst minimising scope for diagnostic error is a challenge. Mismanagement can lead to diagnostic errors, treatment delays, and suboptimal patient outcomes.

Our aim was to explore how UK primary care physicians (GPs) address and communicate diagnostic uncertainty in practice.

This qualitative study used video and audio-recordings. Verbatim transcripts were coded with a modified, validated tool to capture GPs’ actions and communication in primary care consultations that included diagnostic uncertainty. The tool includes items relating to advice regarding new symptoms or symptom deterioration (sometimes called ‘safety netting’). Video data was analysed to identify GP and patient body postures during and after the delivery of the management plan.

Participants

All patient participants had a consultation with a GP, were over the age of 50 and had (1) at least one new presenting problem or (2) one persistent problem that was undiagnosed.

Data collection occurred in GP-patient consultations during 2017–2018 across 7 practices in UK during 2017–2018.

Key results

GPs used various management strategies to address diagnostic uncertainty, including (1) symptom monitoring without treatment, (2) prescribed treatment with symptom monitoring, and (3) addressing risks that could arise from administrative tasks. GPs did not make management plans for potential treatment side effects. Specificity of uncertainty management plans varied among GPs, with only some offering detailed actions and timescales. The transfer of responsibility for the management plan to patients was usually delivered rather than negotiated, with most patients confirming acceptance before concluding the discussion.

Conclusions

We offer guidance to healthcare professionals, improving awareness of using and communicating management plans for diagnostic uncertainty.

Peer Review reports

The management of diagnostic uncertainty is a fundamental challenge in primary care [ 1 ]. Uncertainty can arise from a multitude of factors, including a lack of definitive diagnostic tests, variable presentation of symptoms, and limited access to specialist services [ 2 ]. Furthermore, the communication of diagnostic uncertainty represents a complex challenge for physicians who must balance patient expectations and potential harm from missing a diagnosis with managing over-referral to specialist services. Diagnostic uncertainty has implications for patient safety as its mismanagement can contribute to diagnostic errors, treatment delays or inadequacies, and suboptimal patient outcomes [ 1 , 2 ].

A critical aspect is effective communication of areas of potential uncertainty, both within the healthcare team and with patients. Diagnostic uncertainty is not always discussed with patients in practice, with potential ethical implications for patient autonomy and safety [ 3 , 4 ]. Even when discussed, the linguistic expressions of uncertainty can vary [ 5 ], and the reactions and experiences of patients may differ based on cultural sensitivities and individual preferences [ 6 ].

Reviews of empirical literature have considered how best to manage diagnostic uncertainty, recommending strategies such as using patient-centred communication, acknowledging uncertainty, creating diagnostic ‘safety nets’, and using diagnostic reasoning strategies [ 6 , 7 ]. Even when such strategies are used, they may not be done well. While a variety of methods are used to appraise management of diagnostic uncertainty, (including surveys and qualitative interviews with clinicians; video or audio recorded consultations and experimental techniques [ 2 , 8 , 9 ]) these can struggle to capture the dynamic nature of diagnostic uncertainty [ 9 ]. As a result, there is little empirical evidence on how uncertainty is or should be communicated in primary care.

The practice of creating ‘safety nets’ (commonly referred to as “safety netting” is the UK) is a potentially beneficial method for managing uncertainty [ 10 ]. A safety net is a management plan discussed with the patient to provide specific guidance for uncertain situations, including what to expect and possible outcomes e.g. when and how to seek further medical attention if their symptoms persist or worsen or new symptoms arise [ 11 , 12 , 13 ]. It can mitigate the risk of delayed treatment (and subsequent potentially sub-optimal outcomes)by equipping patients with information on scenarios that require swift action. In addition to advice, it can take the form of safety netting systems e.g. automated reminders to attend specialist appointments [ 2 ]. Effective safety netting acknowledges patients’ information needs, acceptance and understanding [ 14 ], but is challenged by multiple presenting problems, general practitioner (GP) workload and remote consultations [ 13 , 14 , 15 ].

Understanding how diagnostic uncertainty is managed in primary care is essential for improving the safety and efficiency of diagnosis [ 9 ]. Using video data of consultations in primary care, this paper presents an analysis of the management strategies used by primary care physicians in the UK to address uncertainty and their impact on patient care.

Methodological approach

This is a secondary qualitative analysis study applying a validated structured tool [ 16 ] based on a dataset of video and audio-recorded GP-patient consultations collected in Surrey and London, UK in 2017–2018. The tool was designed to record the characteristics of safety netting delivery using video data. Our recordings were collected from 7 GP practices, with 10 participating GPs. The primary aim of data collection was to understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis. Full information on data collection, participant recruitment and ethical approval for this dataset can be found in Amelung et al. [ 17 ].

The total dataset consisted of 200 complete videos, from which we derived a sample of 90 eligible consultation videos for this study according to the following inclusion criteria: all patient participants had a consultation with a GP and had (1) at least one new presenting problem or (2) one persistent problem that was undiagnosed. We selected patients aged 50 or older for our study, as this age group has a higher incidence of cancer than younger populations (see Table  1 ) [ 18 ]. All patient participants and GP participants gave informed consent to have their consultation video-recorded.

Data collection

Video footage of GP-patient consultations was collected using digital and audio-video recording devices. Consultations were recorded in four different GP practices across London and the South East of the United Kingdom.

Ethical considerations

Patients were approached in the practice waiting room and given information about the study to read. Patients and GPs both provided written informed consent to participate in the study and the video recording. All data were stored in a secure manner, and access was restricted to the research team to ensure confidentiality. Audio files were transcribed verbatim and all personally identifiable information was anonymized to protect privacy. Ethical Approval was obtained from London Chelsea Research Ethics Committee (17/LO/0270).

Data Analysis

Coding of verbatim transcripts.

A tool for coding safety netting behaviours in primary care [ 16 ] was applied to the verbatim transcripts by JR and discussed regularly with GB. The tool contains codes relating to:

Problem administration - how many presenting problems, nature of presenting problem.

Diagnostic context - whether the GP communicates a diagnosis.

Follow up codes - whether another consultation is planned.

Nature of safety netting advice.

Initiation of safety netting advice.

Delivery of safety netting.

Conditions/symptoms in safety netting advice.

Actions advised in safety netting advice.

Patient response to safety netting.

Communication format - writing, verbal.

Safety netting documentation.

A full table of the coding tool and response options is freely available from the original Edwards et al. publication [ 16 ]. The verbatim text data were imported and managed in Excel. We modified the tool to capture management of diagnostic uncertainty more widely. The process for this began with identifying instances of diagnostic uncertainty for discussion between JR and GB. After preliminary rounds of coding applying the tool, we added the following additional codes to enable more in depth exploration of how diagnostic uncertainty was managed in primary care consultations (see Supplementary file 1 ).

Coding of video data

After the modified safety netting tool had been applied to the verbatim transcripts, the video data was analysed. Each video was imported into NVIVO qualitative software and the safety netting episode was analysed; deductive codes were generated to identify behavioural aspects of how the GP delivered the management plan for uncertainty (e.g. was the GP facing the patient/computer), how the patient responded behaviourally (e.g. no behavioural response, nodding, shaking head) and what the GP and the patient did immediately after delivering the management plan (see Supplementary file 2 ). These codes were applied to the video data, generating inductive codes during the coding process. The two researchers (JR and LB) coded all videos, compared results and discussed any differences in coding.

Overall, the combination of participant selection, data collection, and analysis methods were designed to enable the study to capture authentic GP and patient interactions in a naturalistic primary care setting. The use of video data provided a unique opportunity to explore the complexity of verbal and non-verbal communication during primary care consultations.

Areas that provoke diagnostic uncertainty for GPs

Undifferentiated and/or persistent symptoms.

GPs frequently advised patients to monitor persistent or worsening symptoms ( n  = 32, 50%), including current symptoms, new symptoms and symptoms that may worsen over time ( n  = 13, 20%). This ‘test of time’ approach included the GP’s suspected diagnosis and a plan for how the persistence of the problem would affect their diagnostic management.

For example, in response to a patient presenting with redness on their shin bone following a fall, a GP explained that the redness could be inflammation or infection and asked the patient to monitor the redness on their leg:

“But what I would encourage you to do is.is to have a mental note…and can I just sort of point out what I’m doing…is that , is this redness here .I think if that begins to spread further I think we…we’d call this cellulitis… there’s some good bone swelling and inflammation and you’re right , you probably bashed the bone…” [GP83] .

Prescription of medication

GPs mainly expressed advice about monitoring symptoms when no treatment was prescribed for the presenting problem and there were no further investigations ( n  = 29, 60%). When GPs expressed uncertainty alongside prescribed home treatment, it was mainly related to whether patients were on the correct treatment or whether the treatment they prescribed was effective ( n  = 18, 28%).

GP: Could you try the cream for a maximum of 2 weeks and… . Patient: Okay. GP: …if it’s not getting better you come back and see us. [GP291]

“If these drops don’t seem to work there are other brands , other types of drops with slightly different ingredients , so if after one to two weeks it’s not feeling better just tell us and we’ll swap to a different antibiotic brand , okay?” [GP61] .

In our dataset, there were no instances where GPs expressed uncertainty about potential side effects of the treatment they prescribed (e.g. if [specified symptoms] occur after using [medication] take [action]). In only two cases, the GP expressed a plan to cover uncertainty regarding whether the patient would adhere to their advice, and offered encouragement to the patient to either take prescribed medication or to attend an investigative procedure.

GP: So even if when you’re taking the tablets all the symptoms get better and you think oh it’s all better now , I don’t need to really go for that horrible camera test… . Patient: Yeah. GP: …you really should because we want to be completely sure about what’s going on inside the oesophagus , why the gullet isn’t squeezing down , things down properly and what’s causing all this extra acid in the first place , okay? [GP158]

Potential administrative errors in the diagnostic process

GPs also expressed uncertainty when they had administrative concerns about patients accessing investigations or secondary care appointments following their primary care appointment. They were concerned that the results of hospital investigations would get lost and patient appointment letters would not arrive.

In this example the patient’s investigative results from secondary care had never reached their GP. The GP referred the patient for a repeat test and asked the patient to request a copy of their own results as a safety net to this error happening again:

“Well the only thing I say this time is…request that you ask for a copy to be given directly … for you to give directly to me (points towards themself) because they will give you a copy of it and then we will be sure if it’s in your hands.” [GP143] .

Similarly, another GP advised the patient to contact the GP surgery if their Urgent Suspected Cancer referral appointment letter did not arrive.

Verbal communications by GPs to patients to manage uncertainty

Plans to manage uncertainty were initiated by GPs with only 8 cases of patients initiating these discussions. It was almost exclusively the responsibility of the patient to take action for any required further consultations (n = 58, 91%).

“Well , if you’re not back to completely normal in another week will you let me know?” [GP105] .

GPs predominantly delivered advice about managing uncertainty during the treatment planning phase of the consultation (n = 50,83%) or at the closing of the consultation (n = 13, 20%). This was invariably delivered as a plan, with a request only for confirmation from the patient:

“I mean , if your hair really starts falling out… it will probably be worth doing those blood tests again , that’s the only sort of thing , that’s … worth doing here really , yes?” [GP228] .

GPs mostly followed the communication format of providing a list of symptoms for patients to monitor or be aware of, followed by an accompanying action for patients to take (n = 57, 89%). In a minority of cases, GPs did not advise any accompanying action for what the patient should do if the symptom arose or persisted (n = 9, 14%). When GPs did advise, the action to take was invariably to return to them personally or to their GP surgery (n = 45, 64%). In 10 cases they directed patients to other services, such as emergency services.

“And I think if this cough has not gone back to how it normally is in another week and you’re not feeling fully better I’d like you to come and see me , and I think we should think about sending you up for some more tests.” [GP105] .

There was substantial variation as to whether GPs also provided patients with a timescale for taking the action advised, with no timescale provided in just over half of cases (n = 36,56%).

“And we’ll leave the antibiotics for time being… unless , you know , it gets worse again.” [GP269] .

GPs tended to use neutral ( n  = 25,39%) or weak language ( n  = 30, 47%) to endorse their advice. Neutral language includes wording such as “come back and see me” or “pop back”, where weak endorsement is expressed as “you could/can come back”.

Communication following the management plan for uncertainty

GPs predominantly communicated the management plan facing the patient, although in some cases they either faced the computer or turned their body back and forth between the computer and the patient. In nearly all cases, as soon as the management plan was delivered, the GP’s body position changed to either turning to face the computer or preparing to usher the patient out of the consultation. This was also reflected verbally; at the end of delivering the management plan, GPs either stopped talking in order to work on their computer, discussed something else (e.g. plans for patient’s investigative tests) or listened to the patient. Patients sat in silence whilst the management plan was delivered, displaying behaviours that signalled understanding or agreement (such as nodding or “uh huh” phrases) or neutral behaviours.

No patient actively disagreed with the plan, one patient used quiet sarcasm, muttering “fab” . At the end of the delivery of the verbal plan patients either changed the topic, sat silently whilst the GP worked on the computer or started to collect their possessions in order to leave the consultation.

The results of this study provide insights into when and how GPs communicate plans to manage diagnostic uncertainty during primary care consultations. A range of management plans were identified, including those related to diagnostic and treatment uncertainties: (1) patients who were not prescribed treatment and needed to monitor existing symptoms or potential new symptoms; 2) patients who were prescribed treatment and needed to monitor symptoms to assess treatment efficacy and 3) risks to the diagnostic process due to administrative problems in the system. There were no management plans for potential side effects of treatment and only one case of using a management plan to mitigate potential lack of adherence. Our findings suggest that the specificity of uncertainty management plans varied, with some GPs providing more detailed information than others regarding required actions, including timescales for when these actions should be taken. We identified that the transfer of responsibility was often delivered rather than negotiated, with patients invited solely to confirm acceptance of the plan before the discussion ended. After the management plan had been delivered, both GPs and patients behaviourally adopted postures that indicated that either discussion or the consultation had ended. We have made some recommendations for the communication of diagnostic uncertainty plans based on our findings (see Table  2 ).

Comparison to previous research

National strategic drivers in the UK such as the NHS Long Term Plan have highlighted patient-led initiatives and patient-activated follow-ups to manage demand for health services, with patients given access to digital records.

We saw that uncertainty caused by administrative gaps that pose risk to diagnostic processes result in physicians transferring responsibility to patients to ensure process completion. This resonates with the growing movement to place patients at the centre of patient safety, with the assumption that patients will check on system performance and quality standards if they know what to expect [ 19 ]. We do not know what the impact of being led to expect suboptimal performance in this manner is on patients, and may detrimentally impact patient outcomes due to decreased trust and confidence in their provider. Research has shown that patients who may have limited or fluctuating capacity to self-manage or self-advocate are at greater risk of negative outcomes, particularly people with serious mental health conditions, learning disabilities and autistic people [ 20 , 21 , 22 ]. Reasonable adjustments in healthcare settings need to include comprehensive and reliable administrative systems to prevent these patients from losing access to healthcare [ 23 ].

The NHS Long Term Plan also centres on shared decision-making as part of the consultation model. Consistent with other studies, our findings demonstrate how diagnostic uncertainty is triggered by ambiguity about the underlying cause of patients’ presenting symptoms [ 3 , 24 ]. Many studies have raised the importance of balancing uncertainty communication with patient-centred strategies. For example, in a realist review of safety netting, recommendations included discussing rather than simply delivering the safety netting plan, with roles negotiated [ 14 ]. However, our study demonstrated that in practice, diagnostic uncertainty plans are mainly delivered by the physician, rather than discussed, and frequently terminate the conversation or consultation.

Despite medication safety being repeatedly identified as the predominant patient safety issue in primary care [ 25 , 26 , 27 ], relatively few studies have examined the relationship between diagnostic uncertainty and medication prescribing. A retrospective observational study found that diagnostic uncertainty was expressed in 16% of visits, particularly in cases where antibiotics were prescribed [ 28 ]. We found no instances of physicians communicating their uncertainty with respect to safety in prescribing medication. This is a missed opportunity, as evidence suggests that patients who are informed about potential side effects of medicine are more likely to take them as recommended [ 29 ]. In their Realist Review, Friedemann Smith [ 14 ] et al. mapped safety netting to the three most common taught consultation models in medical training, showing that making management plans for diagnostic uncertainty can be integrated into practice rather than being seen as an additional task.

To date, the majority of research has focussed on the content of management plans and their delivery rather than their social function within the primary care consultation. One qualitative study supports our findings that these management plans indicate to patients that the GP is ending a discussion or the consultation. Previous studies indicate that patients retain approximately 40% of information given in a consultation, with factors such as anxiety and age of patient and perceived importance of information resulting in lower recall [ 30 ]. If patients deem that they are being dismissed, this may affect their ability to take in information, especially for those who are highly concerned about their health [ 15 , 31 ]. Further research is also needed to explore how these plans play a role in the doctor-patient relationships e.g. by preserving care continuity (I can return) [ 32 ] and potentially relieving immediate anxiety (no/low immediate risk).

Further research is also required to understand patients’ interpretation of safety netting conversations; this includes both comprehension, information retention and the consequences of inferred dismissal or closure. Our adaptation of the Edwards et al. safety netting tool to include other expressions of diagnostic uncertainty may be used in other studies of observational or video data [ 16 ].

Strengths and limitations

This study used both inductive qualitative analysis and a validated observational tool to rigorously analyse diagnostic uncertainty management in routine consultations with primary care patients in the UK. The coding of consultations was done with rigour including double coding and the use of a tool with high interrater reliability. The tool was developed specifically for safety netting, which may limit its applicability to diagnostic uncertainty; however, we added unvalidated items in line with our research objective to mitigate this.

Our study is limited by its small sample of primary care consultations in the UK, and by the historical context of using consultations from 2017 to 2018. Primary care practitioners may approach diagnostic uncertainty differently now, particularly since the advent of more widespread electronic safety netting tools and telephone consultations; [ 33 , 34 ] further research is required to evaluate our proposed recommendations, to assess the uptake of these tools and examine the communication of management plans in a telemedicine context.

We did not measure clinician or patient satisfaction, nor any long term clinical or behavioural outcomes, and therefore cannot comment on the effectiveness of these management plans. The video recording may have influenced physician behaviour; however a methodological review of recording consultations concluded that it does not significantly alter patient or physician behaviour [ 35 ]. We did not collect the sample with the aim of analysing diagnostic uncertainty management, therefore this makes it more likely that physicians were acting in a natural manner with no desirability bias.

A limitation of the study is the broad definition of diagnostic uncertainty [ 2 ]. To prevent bias incurred from coding in a particular way according to our definitions, we worked with a multi-disciplinary team (including primary care clinicians) in the design, analysis and development of recommendations.

Diagnostic uncertainty is a fundamental part of primary care practice, requiring careful management to mitigate potential harm from diagnostic errors, treatment delays and suboptimal patient outcomes. Our study has highlighted potential missed opportunities for using management plans, ways to improve management plans and some of the potential social functions these plans can have in the consultation. Our findings offer guidance to healthcare professionals in primary care and other settings, enhancing awareness of how diagnostic uncertainty is conveyed and managed. Our research provides a methodological springboard for future research aiming to clarify the relationship between expressions of diagnostic uncertainty in practice, management strategies and patient outcomes.

Data availability

Data are available on reasonable request. Contact Dr Georgia Black on [email protected].

Bhise V, et al. Defining and measuring diagnostic uncertainty in Medicine: a systematic review. J Gen Intern Med. 2018;33(1):103–15.

Article   PubMed   Google Scholar  

Alam R, et al. Managing diagnostic uncertainty in primary care: a systematic critical review. BMC Fam Pract. 2017;18(1):79.

Article   PubMed   PubMed Central   Google Scholar  

Cox CL, et al. Diagnostic uncertainty in primary care: what is known about its communication, and what are the associated ethical issues? Fam Pract. 2021;38(5):654–68.

Tompson A, et al. Quality improvements of safety-netting guidelines for cancer in UK primary care: insights from a qualitative interview study of GPs. Br J Gen Pract. 2019;69(689):e819–26.

Meyer AND, et al. Pediatric clinician perspectives on communicating diagnostic uncertainty. Int J Qual Health Care. 2019;31(9):G107–12.

PubMed   Google Scholar  

Dahm MR, et al. Communication of diagnostic uncertainty in primary care and its impact on patient experience: an integrative systematic review. J Gen Intern Med. 2023;38(3):738–54.

Meyer AND, et al. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Couns. 2021;104(11):2606–15.

Bhise V, et al. Patient perspectives on how physicians communicate diagnostic uncertainty: an experimental vignette study. Int J Qual Health Care. 2018;30(1):2–8.

Bhise V, et al. Electronic health record reviews to measure diagnostic uncertainty in primary care. J Eval Clin Pract. 2018;24(3):545–51.

Roland D, et al. Safety netting in healthcare settings: what it means, and for whom? Arch Dis Child Educ Pract Ed. 2014;99(2):48–53.

Almond S, Mant D, Thompson M. Diagnostic safety-netting. Br J Gen Pract. 2009;59(568):872–4. discussion 874.

Jones CHD, et al. The safety netting behaviour of first contact clinicians: a qualitative study. BMC Fam Pract. 2013;14:140.

Evans J, et al. GPs’ understanding and practice of safety netting for potential cancer presentations: a qualitative study in primary care. Br J Gen Pract. 2018;68(672):e505–11.

Friedemann Smith C, et al. Optimising GPs’ communication of advice to facilitate patients’ self-care and prompt follow-up when the diagnosis is uncertain: a realist review of ‘safety-netting’ in primary care. BMJ Qual Saf. 2022;31:541–54.

Black GB, et al. How does safety netting for lung cancer symptoms help patients to reconsult appropriately? A qualitative study. BMC Prim Care. 2022;23(1):179.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Edwards PJ, et al. Development of a tool for coding safety-netting behaviours in primary care: a mixed-methods study using existing UK consultation recordings. Br J Gen Pract. 2019;69(689):e869–77.

Amelung D, et al. Influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study. BMJ Qual Saf. 2020;29(3):198–208.

Cancer incidence by age 2015.

Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care. 2002;11(1):76–80.

Heslop P, Glover G. Mortality of people with intellectual disabilities in England: a comparison of data from existing sources. J Appl Res Intellect Disabil. 2015;28(5):414–22.

Heslop P, et al. Deaths of people with intellectual disabilities: analysis of deaths in England from COVID-19 and other causes. J Appl Res Intellect Disabil. 2021;34(6):1630–40.

Fiorillo A et al. Reducing the mortality gap in people with severe Mental disorders: the role of Lifestyle Psychosocial interventions. 2019: Front Media SA. 170.

Reasonable adjustments: a legal duty 2016.

Green C, Holden J. Diagnostic uncertainty in general practice. Eur J Gen Pract, 2009.

Gaal S, Verstappen W, Wensing M. Patient safety in primary care: a survey of general practitioners in the Netherlands. BMC Health Serv Res. 2010;10:21.

Gaal S, et al. Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses. J Eval Clin Pract. 2010;16(3):639–43.

Spencer R, Campbell SM. Tools for primary care patient safety: a narrative review. BMC Fam Pract. 2014;15:166.

Whaley LE, et al. Visit complexity, diagnostic uncertainty, and antibiotic prescribing for acute cough in primary care: a retrospective study. BMC Fam Pract. 2013;14:120.

Lowe CJ, et al. Effects of a medicine review and education programme for older people in general practice. Br J Clin Pharmacol. 2000;50(2):172–5.

Kessels RP. Patients’ memory for medical information. J R Soc Med. 2003;96(5):219–22.

PubMed   PubMed Central   Google Scholar  

Hovey RB, et al. Partners in our care: patient safety from a patient perspective. Qual Saf Health Care. 2010;19(6):e59.

CAS   PubMed   Google Scholar  

Beck Nielsen S. If you don’t get better, you may come back here: proposing conditioned follow-ups to the doctor’s office. Text Talk - Interdiscip J Lang Discourse Commun Stud. 2018;38(2):217–42.

Google Scholar  

Ip A, et al. Socioeconomic differences in help seeking for colorectal cancer symptoms during COVID-19: a UK-wide qualitative interview study. Br J Gen Pract. 2022;72(720):e472–82.

Black GB et al. Using an electronic safety netting tool designed to improve safety with respect to cancer referral in primary care: a qualitative service evaluation using rapid appraisal methods. BMJ Open Qual, 2023. 12(3).

Themessl-Huber M, et al. Audio-visual recording of patient-GP consultations for research purposes: a literature review on recruiting rates and strategies. Patient Educ Couns. 2008;71(2):157–68.

Download references

Acknowledgements

We would like to take this opportunity to thank the GP practices and patients who participated in our study as well as our funder.

This project was funded by Blood Cancer UK. This work was supported by GBB’s postdoctoral Fellowship from The Institute of Healthcare Improvement Studies (University of Cambridge) (RG88620/PD-2019-02-004). GBB also acknowledges funding from Barts Charity (G-001520).

Author information

Authors and affiliations.

Wolfson Institute of Population Health, Queen Mary University of London, London, UK

Jessica Russell & Georgia B. Black

School of Health Sciences, The University of Surrey, Surrey, UK

Laura Boswell, Athena Ip, Jenny Harris & Katriina L. Whitaker

Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX, USA

Hardeep Singh, Ashley N. D. Meyer & Traber D. Giardina

General Practitioner, Cancer GP lead for North Central London Cancer Alliance, London, UK

Afsana Bhuiya

You can also search for this author in PubMed   Google Scholar

Contributions

All authors made substantial contributions to the conception and design of this article. GBB and JR conceived the study idea. JR, GBB and LB contributed to data analysis. All authors(JR, LB, AI, JH, HS, AM, TG, AB, KW, GBB) contributed to interpretation of the data. JR and GBB drafted the article. All co-authors revised the article critically for important intellectual content and gave final approval of the version submitted.

Corresponding author

Correspondence to Jessica Russell .

Ethics declarations

Ethics approval and consent to participate.

This is a secondary analysis of an existing dataset that has prior ethical approval and ethical approval was unnecessary.

Competing interests

The authors declare no competing interests.

Patient and public involvement statement

This is a secondary analysis of an existing dataset. For full information on PPI in data collection and analysis see Amelung D, Whitaker KL, Lennard D, et al. Influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study. BMJ Qual Saf . 2020;29(3):198–208.

Additional information

Publisher’s note.

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

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, 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/ .

Reprints and permissions

About this article

Cite this article.

Russell, J., Boswell, L., Ip, A. et al. How is diagnostic uncertainty communicated and managed in real world primary care settings?. BMC Prim. Care 25 , 296 (2024). https://doi.org/10.1186/s12875-024-02526-x

Download citation

Received : 14 February 2024

Accepted : 16 July 2024

Published : 12 August 2024

DOI : https://doi.org/10.1186/s12875-024-02526-x

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

• Health communication
• Primary care
• Video recording
• Patient safety
• Consultation
• Safety netting
• Uncertainty

BMC Primary Care

ISSN: 2731-4553

• General enquiries: [email protected]