- Impaired Verbal Communication related to dysarthria (weakened muscles used for speech) and Aphasia (impaired ability to comprehend or produce language) as evidenced by Slurred speech and Difficulty expressing thoughts
- Ineffective Cerebral Tissue Perfusion related to Interruption of blood flow to the brain and thrombus formation as evidenced by Slurred speech and extremity weakness
- Risk For Injury related to Poor motor coordination and Poor balance as evidenced by Paralyzed skin and Limbs
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Express difficulty to speak Objective data: -Slurred speech -Nonverbal -Difficulty forming words -Difficulty expressing thoughts -Slow to respond due to delayed comprehension -Extremity weakness or paralysis resulting in an inability to write or type | Impaired Verbal Communication Related to dysarthria (weakened muscles used for speech) and Aphasia (impaired ability to comprehend or produce language) as evidenced by Slurred speech and Difficulty expressing thoughts | Patient will establish a form of communication to express their thoughts and needs Patient will participate in speech therapy to improve communication Patient will utilize resources and devices to support communication | 1. Speak in short, direct sentences. Always speak clearly, facing the patient so they can see your lips and expressions. Use direct sentences as they may not be able to comprehend abstract thoughts. Short “yes” or “no” questions may be easiest for the patient to comprehend. 2. Utilize alternative communication methods. Use writing, drawing, and flashcards if these work for the patient. The nurse and patient may be able to work out a system to communicate needs such as a thumbs up or down, eye blinking, or smiling if they are nonverbal. 3. Encourage speech therapy. Speech-language therapy is vital in improving communication. Aphasia can improve over time and speech therapy can help the patient restore language abilities as well as instruct on devices and technology to aid in communicating. 4. Encourage family participation. Family involvement is crucial as both the patient and family learn to maneuver communication changes. Family members should also participate in therapy sessions and learn specific techniques that support clear communication | Patient established a form of communication to express their thoughts and needs Patient will participate in speech therapy to improve communication Patient will utilize resources and devices to support communication |
| Subjective data: Chest Pain Dyspnea Sense of impending doom Objective data: -Arrhythmias -Capillary refill >3 seconds -Altered respiratory rate -Use of accessory muscles to breathe -Abnormal arterial blood gases -Unstable blood pressure -Tachycardia or bradycardia -Cyanosis | Ineffective Cerebral Tissue Perfusion related to Interruption of blood flow to the brain and thrombus formation as evidenced by Slurred speech and extremity weakness | Patient will recognize symptoms of a stroke and seek immediate medical attention Patient will display improved cerebral perfusion as evidenced by vital signs within ordered parameters Patient will display improvement in stroke deficits such as slurred speech, weakness, and swallowing ability by discharge | 1. Maintain blood pressure. To maintain cerebral perfusion, blood pressure is kept elevated. For ischemic strokes, the blood pressure may be allowed as high as 220 systolic (unless receiving thrombolytic therapy) and no lower than 140 systolic for a hemorrhagic stroke. Specific parameters will be ordered by the provider. 2. Administer thrombolytics. Thrombolytics are administered to dissolve clots in an ischemic stroke. They should never be administered for a hemorrhagic stroke as this will cause fatal bleeding. Also, thrombolytics must be administered within 4 hours of the development of stroke symptoms to be effective. 3. Educate on risk factors of strokes. If the patient only experiences a TIA or does not suffer long-term deficits from a stroke, prevention of a future stroke should be communicated. Risk factors include hypertension, heart disease, diabetes, smoking, and stress. These are modifiable risk factors that the patient can work towards changing through diet, exercise, and lifestyle behaviors. 4. Instruct on symptoms of a stroke using FAST. “Time is tissue” in the instance of a stroke. The sooner symptoms are recognized, the quicker the treatment, and less sustained damage to brain tissue. Patients and family members should be instructed on the acronym F.A.S.T which stands for Facial drooping, Arm weakness, Speech difficulty, and Time (call Emergency Number). | Patient recognized symptoms of a stroke and seek immediate medical attention Patient displayed improved cerebral perfusion as evidenced by vital signs within ordered parameters Patient displayed improvement in stroke deficits such as slurred speech, weakness, and swallowing ability by discharge |
| Subjective data: Express increased risk for falls and Injury Objective data: -Impaired sensory awareness -Dysphagia -Inability to communicate -Hemiplegia -Short attention span -Impulsivity | Risk For Injury related to Poor motor coordination and Poor balance as evidenced by Paralyzed skin and Limbs | Patient will remain free from falls Patient will maintain intact skin integrity Caregivers will support the patient and create a modified environment to keep the patient safe and free from injury | 1. Use bed and chair alarms. When patients suffer a right-brain stroke specifically, they may be more impulsive and deny or minimize their deficits. This puts them at high risk for injury and falls. Keeping a bed alarm on at all times and a chair alarm if they are sitting up will increase safety. 2. Assist with eating. Patients with dysphagia will require special meals and thickened liquids. Ensure they are chewing and swallowing adequately and are not displaying signs of possible aspiration such as pocketing food, drooling, or coughing. 3. Teach to scan the environment. If the patient has left or right-sided neglect or visual disturbances teach them to scan from left to right. This can help them when moving in their environment but also assist with activities such as reading. 4. Turn and assess skin frequently. If the patient is paralyzed on one side and lacks sensation it is the nurse’s responsibility to maintain their skin integrity. Turn every 2 hours, keep boney areas supported, maintain proper alignment of extremities and ensure lines and tubes are not digging into the patient’s skin. | Patient remained free from falls Patient maintained intact skin integrity Caregivers supported the patient and create a modified environment to keep the patient safe and free from injury |