Nursing care plan for ischemic stroke

Introduction to Nursing Care Plan for Ischemic Stroke

Ischemic stroke occurs when an arterial blockage in the brain prevents oxygen-rich blood from reaching nerve cells, which can lead to injury or death of the cells. A nursing care plan provides a roadmap to meet the individual needs of a patient throughout the rehabilitation process. This care plan includes assessment, nursing diagnosis, outcomes, interventions, rationales, evaluation and conclusion.

Assessment

The assessment phase of the nursing care involvement aims to identify the biopsychosocial context of the patient as well as any complications resulting from ischemic stroke. It also determines the patient’s cognitive, physical, emotional and psychosocial functioning.

• Medical History - Includes medical records and information about current medications, treatments and past medical conditions.
• Vitals Signs - Monitoring for risk of sudden changes in the patient's condition and maintaining general health.
• Neurological Status - Observations of motor, sensory and mental functions of the central nervous system.
• Behavior - Assessment of the patient's response and attitude towards treatment and care.

Nursing Diagnosis

Nursing diagnosis is the clinical judgment about individual, family and community responses to actual or potential health problems, which may be prioritized in order of significance.

• Impaired Physical Mobility - Loss of ability to independently move the body due to weakness, paralysis or immobility.
• Ineffective Coping - Inability to cope with everyday tasks due to physical, emotional or cognitive limitations.
• Pain - Ischemic stroke can cause migraines, facial pain, back pain and the other discomforts.
• Risk for Self-Care Deficit - The patient relies on or needs assistance with activities of daily living.

Outcomes

Outcomes are the expectations of desired improvement that nurses develop in collaboration with patients as part of their individualized care plan.

• Patient will practice Self-care - Self-care strategies taught during therapeutic sessions will enable the patient to become more independent in everyday activities.
• Patient will verbalize Coping Strategies - Discussing ways the patient can manage feelings of frustration, anxiety or helplessness.
• Patient will reduce Pain - Use of Pharmaceuticals, relaxation techniques or distraction techniques can help reduce the pain related to ischemic stroke.
• Patient will demonstrate Improved Mobility - Implementation of physical therapies, occupational therapies or verbal directives to improve motor function.

Interventions

Interventions are specific evidence-based actions selected to set goals and enhance independent functioning.

• Encourage Appropriate Self-Care Activities - Practicing activities such as brushing teeth, bathing and dressing depending on the patient's level of impairment.
• Utilize Positive Reinforcement - Applauding successes, successes small and large, as well as offering encouragement.
• Instruct in Stress Management Techniques - Teaching deep breathing, progressive muscle relaxation and yoga to enable the patient to cope better.
• Provide Assistance with walking - Assisting the patient in walking with gait belts, manual wheelchair, orthoses and other assistive devices.

Rationales

Rationales are the reasons behind the selection of certain interventions and explain why these interventions are beneficial to the patient.

• Self-care activities - increases sense of control, builds confidence, and helps improve overall functioning.
• Positive reinforcement - encourages progress in the patient and fosters positive relationships between the patient and his/her healthcare providers.
• Stress management - teaches the patient how to better manage stress and fear while managing symptoms.
• Walking assistance - reduces risk of falls, helps improve balance and stability, and improves mobility.

Evaluation

Evaluation assesses the success of interventions and identifies any adjustments that need to be made to ensure best outcomes for the patient. Evaluation methods include reports, interview questions and surveys.

Conclusion

A nursing care plan for ischemic stroke is an important step to ensure that every patient receives the highest level of care. Through assessment, nursing diagnosis, outcomes, interventions, rationales and evaluation, individualized care plans are developed to best meet the unique needs of each patient.

FAQs

• What is the purpose of a nursing care plan? - The purpose of a nursing care plan is to provide a roadmap to meet the individual needs of a patient throughout the rehabilitation process.
• What is included in an assessment? - An assessment includes medical history, vitals signs, neurological status and behavioral assessment.
• What type of interventions are used for ischemic stroke care? -Interventions can include encouraging appropriate self-care activities, utilizing positive reinforcement, instructing in stress management techniques and providing assistance with walking.
• What is the purpose of rationales? - Rationales are the reasons behind the selection of certain interventions and explain why these interventions are beneficial to the patient.
• What type of methods should be used for evaluating the success of interventions? - Evaluation methods include reports, interview questions and surveys.