Medical Surgical Nursing

Nursing Process

The Patient Recovering From an Ischemic Stroke

The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of
all body systems is essential as long as the patient requires care. The patient who has
had a stroke is at risk for multiple complications, including deconditioning and other
musculoskeletal problems, swallowing difficulties, bowel and bladder dysfunction,
inability to perform self-care, and skin breakdown. After the stroke is complete,
management focuses on the prompt initiation of rehabilitation for any deficits.

Assessment
During the acute phase, a neurologic flow sheet is maintained to provide data about the
following important measures of the patient's clinical status:

 Change in level of consciousness or responsiveness as evidenced by movement,

resistance to changes of position, and response to stimulation; orientation to

time, place, and person

 Presence or absence of voluntary or involuntary movements of the extremities;

muscle tone; body posture; and position of the head

 Stiffness or flaccidity of the neck

 Eye opening, comparative size of pupils and pupillary reactions to light, and

ocular position

 Color of the face and extremities; temperature and moisture of the skin

 Quality and rates of pulse and respiration; arterial blood gas values as indicated,

body temperature, and arterial pressure

 Ability to speak

 Volume of fluids ingested or administered; volume of urine excreted each 24

hours

 Presence of bleeding

 Maintenance of blood pressure within the desired parameters

After the acute phase, the nurse assesses mental status (memory, attention span,
perception, orientation, affect, speech/language), sensation/perception (usually the
patient has decreased awareness of pain and temperature), motor control (upper and
lower extremity movement), swallowing ability, nutritional and hydration status, skin
integrity, activity tolerance, and bowel and bladder function. Ongoing nursing
assessment continues to focus on any impairment of function in the patient's daily
activities, because the quality of life after stroke is closely related to the patient's
functional status.

Diagnosis
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses for a patient with a stroke
may include the following:

 Impaired physical mobility related to hemiparesis, loss of balance and

coordination, spasticity, and brain injury

 Acute pain (painful shoulder) related to hemiplegia and disuse

 Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding)

related to stroke sequelae