14 Stroke (CVA) Nursing Diagnosis and Nursing Care Plans

A stroke is brain tissue dying by the minute. Your job at the bedside is to catch the deficit early, protect the airway and the swallow, keep intracranial pressure down, and move the patient toward reperfusion or surgery before more brain is lost. The faster circulation is restored, the better the recovery. About half of survivors stay permanently disabled, and recurrence is common, so prevention starts the day they arrive.

What is Cerebrovascular Accident (CVA) or Stroke?

Cerebrovascular accident (CVA), also called stroke, acute ischemic stroke, cerebral infarction, or brain attack, is the sudden impairment of cerebral circulation in one or more vessels supplying the brain. The vessel either tears and bleeds or gets occluded, with transient or permanent effects.

Thrombosis, embolism, and hemorrhage are the primary causes, with thrombosis leading both CVAs and transient ischemic attacks (TIAs). The carotid arteries and the vertebrobasilar system at the base of the brain are most often involved.

Strokes are either ischemic or hemorrhagic. Acute ischemic stroke comes from thrombotic or embolic occlusion of a cerebral artery and presents in predictable syndromes based on which territory loses flow. Intracerebral hemorrhage (ICH), the second most common type, usually comes from rupture of small arteries secondary to hypertensive vasculopathy, cerebral amyloid angiopathy (CAA), coagulopathies, and other vasculopathies.

The TOAST classification divides ischemic strokes into three subtypes: large-artery, small-vessel, and cardioembolic. Large-artery infarctions involve thrombotic occlusions on atherosclerotic lesions in the carotid, vertebrobasilar, and cerebral arteries proximal to major branches. Cardiogenic emboli are a common source of recurrent strokes, account for up to 20% of acute strokes, and carry the highest 1-month mortality. Small-vessel (lacunar) strokes come from obstruction of single deep penetrating arteries.

Stroke is the leading cause of disability and the fifth leading cause of death in the United States. Worldwide, 15 million people have a stroke each year; 5 million die and another 5 million are left permanently disabled. Prognosis after acute ischemic stroke varies widely with stroke severity, premorbid condition, age, and poststroke complications.

Nursing Care Plans and Management

Priorities depend on the phase. During the acute phase, focus on survival and preventing further damage: continuous neurologic assessment, respiratory support, vital sign monitoring, careful positioning to avoid aspiration and contractures, GI management, and electrolyte and nutritional monitoring.

Nursing Problem Priorities

• 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 CT or MRI imaging to confirm the diagnosis and stroke type.
• Implement time-sensitive treatments such as thrombolytic therapy or mechanical thrombectomy when appropriate.
• Provide supportive care to manage complications and promote recovery, including blood pressure control and prevention of secondary brain injury.
• Coordinate an individualized stroke care plan with the team.
• Facilitate physical, occupational, and speech therapy to optimize functional recovery.
• Educate patients and caregivers on risk factors, prevention, and warning signs of recurrence.
• Offer emotional support and counseling during recovery.

Nursing Assessment

Assess for the following subjective and objective data:

• See nursing assessment cues under Nursing Interventions and Actions.

Nursing Diagnosis

After assessment, formulate nursing diagnoses based on clinical judgment and the patient's unique condition. Diagnostic labels organize care, but in practice it is the nurse's judgment that shapes the plan around each patient's priorities.

Nursing Goals

Goals and expected outcomes may include:

• The patient will maintain the usual or improved level of consciousness, cognition, and motor/sensory function.
• The patient will demonstrate stable vital signs and no signs of increased ICP.
• The patient will display no further deterioration or recurrence of deficits.
• The patient will maintain or increase strength and function of the affected or compensatory body part [specify].
• The patient will maintain optimal position of function, free of contractures and foot drop.
• The patient will demonstrate techniques and behaviors that enable resumption of activities.
• The patient will maintain skin integrity.
• The patient will indicate an understanding of the communication problems.
• The patient will establish a method of communication in which needs can be expressed.
• The patient will use resources appropriately.
• The patient will report decreased pain [specify with pain scale].
• The patient will perform activities for recovery and rehabilitation.
• The patient will demonstrate no side effects from analgesics.
• The patient will verbalize acceptance of self in the situation.
• The patient will communicate with significant others (SO) about the situation and changes that have occurred.
• The patient will verbalize awareness of their own coping abilities.
• The patient will meet psychological needs through appropriate expression of feelings, identification of options, and use of resources.
• The patient will demonstrate techniques and lifestyle changes to meet self-care needs.
• The patient will perform self-care activities within their ability.
• The patient will identify personal and community resources for assistance.
• The patient will participate in prescribed physical activity with appropriate changes in heart rate, blood pressure, and respiratory rate.
• The patient will state symptoms of adverse effects of exercise and report them immediately.
• The patient will verbalize the need to gradually increase activity based on tolerance.
• The patient will demonstrate increased activity tolerance.
• The patient will acknowledge the presence of impairment.
• The patient will demonstrate techniques that minimize unilateral neglect.
• The patient will care for both sides of the body and keep the affected side free from harm.
• The patient will return to the optimal functioning level possible.
• The patient will be free from injury.
• The patient and SO will display methods that improve ambulating and transferring.
• The patient will show no shoulder subluxation or shoulder-hand syndrome.
• The patient will interact appropriately with the environment without injury from sensory or perceptual deficit.

Nursing Interventions and Actions

1. Assessing and Monitoring Mental Status

Ischemic stroke starts with loss of blood supply to a focal area. The central core dies within minutes (the infarct). Around it, reduced flow drains energy stores, throws off ionic balance, and eventually destroys cell membranes. Constant reassessment is how you catch the brain that is still salvageable slipping away.

Assess airway patency and respiratory pattern. Stroke can knock out the gag and cough reflex, so airway and breathing come first. Patients with a decreased level of consciousness may not protect their own airway. Hemorrhagic stroke especially can deteriorate fast.

Assess factors related to decreased cerebral perfusion and the potential for increased intracranial pressure (ICP). A full neurologic exam guides therapy. Even an ICP elevation of 5 mm Hg above pre-stroke levels can sharply cut blood flow through the collateral-supplied arterioles feeding the ischemic penumbra, making ICP a dominant cause of collateral failure and early neurological deterioration.

Recognize the clinical manifestations of a transient ischemic attack (TIA). TIA produces temporary neurologic symptoms (sudden loss of motor, sensory, or visual function) with no infarct on imaging. About 15% of all strokes are preceded by a TIA, so prompt evaluation and treatment can prevent the completed stroke.

Frequently assess and monitor neurological status. Track level of consciousness, response to stimulation, orientation, eye-opening, and pupillary reactions. This shows the location, extent, and progression of damage, the potential for increased ICP, and any TIA warning of impending thrombotic CVA.

Monitor changes in blood pressure, and compare readings in both arms. Hypertension is a major risk factor and is common at presentation. Pressure usually falls spontaneously over time. A difference between arms may signal subclavian artery blockage. Hypotension may reflect shock, and rising ICP may reflect edema or clot. If the patient is eligible for fibrinolytic therapy, blood pressure control is essential to reduce bleeding risk.

Monitor heart rate and rhythm, and assess for murmurs. Bradycardia can follow brain damage. Dysrhythmias and murmurs may reflect cardiac disease that triggered the CVA (stroke after MI or valve dysfunction). Atrial fibrillation raises embolic risk. Stroke can occur alongside acute MI and acute heart failure, so listen for murmurs and gallops.

Monitor respirations, noting patterns and rhythm, including Cheyne-Stokes respiration. Irregular respiration can localize the insult or signal rising ICP. Ischemic strokes rarely compromise the airway immediately unless large or involving the brainstem; intracerebral or subarachnoid hemorrhage often needs airway protection and ventilation.

Evaluate pupils, noting size, shape, equality, and light reactivity. Pupil reactions run through the oculomotor (III) cranial nerve and help confirm an intact brainstem. Light response reflects the combined function of the optic (II) and oculomotor (III) nerves. Oculomotor palsy is associated with increased risk of subsequent stroke.

Document changes in vision: blurred vision, visual field loss, depth perception problems. Specific visual changes localize the area involved. Spatial inattention can keep the patient from attending to the stroke-affected side.

Assess higher functions, including speech, if the patient is alert. Changes in cognition and speech localize and grade cerebral involvement and may signal deterioration or rising ICP. Family or bystanders may be needed to pin down the exact onset time, especially in right hemispheric strokes with neglect or left hemispheric strokes with aphasia.

Assess for nuchal rigidity, twitching, restlessness, irritability, and seizure activity. Nuchal rigidity may indicate meningeal irritation. Seizures may reflect rising ICP or cerebral injury and occur in 2 to 23% of patients within the first days after an ischemic stroke. Some patients go on to develop chronic seizure disorders.

Use the National Institutes of Health Stroke Scale (NIHSS) to grade neurologic impairment. The NIHSS quickly establishes severity and likely location. Scores predict outcomes and help identify who will benefit from reperfusion therapy and who is at higher risk of complications.

Screen the patient for stroke risk. Risk factors are modifiable and nonmodifiable. Identifying them points to cause and to the right secondary prevention plan. Migraine with aura is a strong risk factor for any type of stroke.

Monitor blood glucose levels. Both hypoglycemia and hyperglycemia can mimic ischemic stroke and aggravate ongoing neuronal ischemia, so identify and treat them early.

Position with the head slightly elevated and in a neutral position. This promotes venous drainage and may improve cerebral perfusion. During the acute phase, keep the head of the bed at less than 30 degrees. Do not keep the patient flat longer than 24 hours, since lying flat raises ICP and prolonged immobilization brings its own complications.

Maintain bed rest, provide a quiet environment, and restrict visitors and activities. Cluster nursing interventions, provide rest periods, and limit the duration of procedures. Continuous stimulation raises ICP. Absolute rest may be needed to prevent rebleeding. Maximum cerebral edema is typically reached 72 to 96 hours after onset.

Prevent straining at stool, breath-holding, and physical exertion. The Valsalva maneuver raises ICP and the risk of rebleeding. Significant cerebral edema after ischemic stroke is relatively rare (10 to 20%), and early ischemic changes on noncontrast CT predict swelling and deterioration.

Stress smoking cessation. Smoking is a well-established risk factor for all forms of stroke and raises stroke risk 3 to 4 times. Offer counseling, nicotine replacement, and cessation medications. Nurses are frontline in planning and delivering cessation interventions.

Administer supplemental oxygen as indicated. This reduces hypoxemia, which causes cerebral vasodilation and worsens pressure or edema. Give supplemental oxygen when oxygen saturation is below 95%.

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. Surgery may be needed to reduce neurological symptoms and, in selected patients, lowers mortality compared with medical management alone. Options include minimally invasive hematoma evacuation by endoscopic or stereotactic aspiration, external ventricular drain insertion, and craniotomy.

2. Improving Physical Mobility and Preventing Contractures

A stroke disrupts the brain's ability to selectively activate muscle, so the patient loses the ability to move on command. Your goal is to keep joints functional and aligned, reduce spasticity, prevent edema, and head off the complications of immobility while the patient relearns movement.

Assess the extent of impairment and functional ability. Classify on a 0 to 4 scale. This identifies strengths and deficits and guides intervention, since flaccid and spastic paralysis need different techniques. Many patients will need continuing help with ADLs after discharge.

Monitor the lower extremities for thrombophlebitis. Bed rest raises the risk of deep vein thrombosis (DVT), which occurs in 10 to 75% of immobilized post-stroke patients and can be fatal if it leads to pulmonary emboli. Unequal pulses or pressures may also reflect aortic dissection.

Observe the affected side for color, edema, or other signs of compromised circulation. Edematous tissue is easily traumatized and heals slowly. When muscles and joints stop moving after a stroke, lymph flow drops and fluid builds in the affected tissue.

Inspect skin regularly, especially over bony prominences. Gently massage reddened areas and use aids such as sheepskin pads. Bony prominences are most at risk for breakdown. Weakness or paralysis on one side limits the patient's ability to shift weight, so circulatory stimulation and padding help prevent breakdown.

Change positions at least every 2 hours (supine, side-lying), and more often on the affected side. Frequent repositioning reduces tissue injury. Place a pillow between the legs before side-lying. Avoid acute flexion of the upper thigh to promote venous return and prevent edema. Limit time on the affected side because of poorer circulation, reduced sensation, and breakdown risk. Prolonged supine positioning can increase ICP.

Position prone once or twice a day if tolerated, monitoring respirations. For 15 to 30 minutes at a time, place the patient prone with a pillow under the pelvis. This hyperextends the hip joints, helps normalize gait, prevents knee and hip flexion contractures, and drains bronchial secretions.

Prop extremities in a functional position; use a footboard during flaccid paralysis. Keep the head neutral. This prevents contractures and foot drop and preserves use when function returns. Flaccid paralysis impairs head support; spastic paralysis deviates the head to one side.

Use an arm sling when the patient is upright. During flaccid paralysis, a sling reduces the risk of shoulder subluxation and shoulder-hand syndrome, supports the arm, and relieves strain on muscles and joints.

Evaluate the need for positional aids and splints during spastic paralysis. Flexion contractures occur because flexors are stronger than extensors. Custom-fitted splints and props support and gently stretch affected hand and wrist muscles and joints.

Place a pillow under the axilla to abduct the arm. With limited external rotation, a pillow in the axilla keeps the arm off the chest. Position the arm neutral with distal joints higher than proximal joints to prevent shoulder adduction and elbow flexion. When lying on the weaker side, support the head and weaker shoulder on pillows.

Elevate the arm and hand. This promotes venous return and prevents edema. Match the degree and duration of elevation to the patient's condition, since excessive or prolonged elevation can reduce blood flow or cause discomfort.

Place hard hand rolls in the palm with the fingers and thumb opposed. Hand rolls reduce finger flexion stimulation and keep the hand functional. Do not use a hand roll on a spastic upper extremity, since it triggers the grasp reflex; instead place the hand palm up with the fingers barely flexed and prevent edema.

Place the knee and hip in extension. Keep the leg neutral with a trochanter roll. This maintains a functional position and prevents external hip rotation. When supine, place the stronger leg forward on pillows with the weaker leg straight.

Discontinue the footboard when appropriate. After a change from flaccid to spastic paralysis, continued use puts excessive pressure on the ball of the foot, enhances spasticity, and increases plantar flexion.

Help the patient develop sitting and standing balance. This retrains neuronal pathways and improves proprioception and motor response. Raise the head of the bed, help the patient sit at the edge, and have them use the strong arm and leg to support and move. Build standing balance with flat walking shoes, support the lower back, brace your knees outside the patient's knees, and use parallel bars.

Get the patient up in a chair as soon as vital signs are stable, except after cerebral hemorrhage. This restores vasomotor tone and BP, keeps extremities functional, and empties the bladder, reducing the risk of stones and infection from stasis. With an incomplete stroke, activity raises the risk of additional bleeding.

Position and align extremities correctly. Use high-top sneakers to prevent foot drop and contracture, convoluted foam, flotation or pulsating mattresses, or sheepskin. Pad the chair seat with foam or a water cushion, and help the patient shift weight frequently. These prevent pressure injuries. Use pillows to support affected limbs, especially heels and elbows. Specialized mattresses reduce pressure for patients who cannot reposition themselves.

Provide an egg-crate mattress, water bed, flotation device, or specialized bed as indicated. These distribute weight, reduce pressure over bony points, enhance circulation, reduce venous stasis, and help prevent breakdown and orthostatic pneumonia.

Begin active or passive range-of-motion (ROM) exercises on admission to all extremities, including splinted ones. Encourage quadriceps and gluteal exercises, squeezing a rubber ball, and extension of the fingers and legs/feet. Active ROM maintains strength, minimizes atrophy, promotes circulation, and prevents contractures; passive ROM maintains joint flexibility. Put affected extremities through passive ROM about 5 times a day. Exercise also prevents venous stasis and reduces venous thromboembolism risk.

Encourage the patient to use the unaffected extremities to support and move the weaker side. The patient may treat the affected side as no longer part of the body and needs active training to reincorporate it. Exercise drives neuroplasticity, the rewiring that is the primary goal of stroke rehabilitation. The more the patient practices, the better the brain relearns to signal the affected muscles.

Perform ROM exercises on both the affected and unaffected sides. Teach the patient to use the unaffected side to exercise the affected side. Frequent repetition forms new neural pathways. Early on, extremities are usually flaccid and tight, so do ROM more frequently. Passive exercise still reduces stiffness and prevents complications.

Use a "start low and go slow" approach. Frequent short periods beat long infrequent ones. Daily exercise is the only way to build strength and maintain ROM. Results take time, but consistent work improves mobility and function.

Monitor for pulmonary embolism or cardiac overload during exercise. Shortness of breath, chest pain, cyanosis, and increased pulse may indicate PE or excessive cardiac workload. Provide DVT prophylaxis.

Set goals with the patient and SO for participation in activities and position changes. This builds expectation of improvement and a sense of control. AHA/ASA recommends at least 3 hours each day of tailored rehabilitation at inpatient facilities by a coordinated team.

Incorporate fall prevention strategies. Once a stroke patient falls and is injured, recovery stalls and deterioration accelerates. Educate the patient and family on drug side effects that affect balance, removing home obstacles, good lighting, and proper use of walkers, wheelchairs, and canes.

3. Managing Aphasia and Promoting Effective Communication

Aphasia, a language disorder, affects about 30% of acute stroke patients, and more than half of those have moderate-to-severe aphasia in the first weeks. It disrupts communication for the patient, the family, and the staff, so identifying the type guides every intervention.

Differentiate aphasia from dysarthria. This localizes and grades the brain involvement. Aphasia affects the ability to speak, read, write, and listen. Dysarthria is loss of the ability to articulate, a motor problem with the muscles of speech.

Assess the patient for aphasia. Aphasia is loss of the ability to understand or express speech. Receptive aphasia (Wernicke's area damage) produces wrong or meaningless words. Expressive aphasia (Broca's area injury) makes forming or understanding sentences hard. Patients may have either or both. The Boston Diagnostic Aphasia Examination (BDAE) helps diagnose it.

Assess the patient for dysarthria. In dysarthria the speech muscles are damaged, paralyzed, or weak, so the patient comprehends, reads, and writes but cannot pronounce words. The patient may not monitor verbal output or realize speech is not making sense. Neuropsychological testing helps plan treatment.

Ask the patient to follow simple commands ("Close and open your eyes," "Raise your hand") and to repeat simple words or sentences. This tests for Wernicke (receptive) aphasia, where output is fluent and normally paced but the content is hard to follow because of paraphasic errors. Test verbal fluency, naming, repetition, comprehension, reading, and writing.

Point to objects and ask the patient to name them. This tests for Broca (expressive) aphasia, where spontaneous speech is markedly reduced and grammar breaks down. The patient may recognize an item but not name it.

Have the patient produce simple sounds ("dog," "meow," "Shh"). This identifies dysarthria, since damage to the motor components of speech (tongue, lips, breath control) affects articulation. Dysarthric speech may be jerky, staccato, breathy, irregular, imprecise, or monotonous depending on the site of damage.

Assess for depression. Aphasia frustrates patients, and the inability to communicate can cause anger and hopelessness. Patients with Broca aphasia are often very upset, both from the deficit and from damage to adjacent frontal structures that inhibit negative emotions. Address post-stroke depression and cognitive impairment to optimize the outcome, and stay sensitive to the patient's reactions.

Differentiate the patient's symptoms from Alzheimer dementia. In both, the patient may struggle with orientation questions. In Wernicke aphasia the deficit is comprehension; in dementia it is memory. Alzheimer disease is subacute and progressive, while Wernicke aphasia is sudden from ischemic stroke.

Listen for errors in conversation and provide feedback. Feedback helps the patient see why caregivers are not understanding and gives a chance to clarify. A trusting relationship where the patient feels understood relieves emotional distress.

Ask the patient to write their name and a short sentence; if unable to write, have them read a short sentence. This tests for agraphia (writing disability) and alexia (reading comprehension deficits). Abnormal spelling is an early clue to Wernicke aphasia.

Post a notice at the nurses' station and in the room about the speech impairment. Provide a call bell that activates with minimal pressure. Anticipate the patient's needs. This eases anxiety over not being able to communicate and the fear that needs will go unmet. Patients value being seen and feeling heard.

Provide alternative methods of communication. A communication board with pictures of common needs and phrases helps. Augmentative and alternative communication (AAC) systems, including Visual Scene Displays that use personally relevant photographs with text and speech output, compensate for persistent language deficits.

Talk directly to the patient, slowly and distinctly. Gain attention first. Phrase questions for yes or no answers, then progress in complexity as the patient responds. This avoids overwhelming the patient with too much to process at once. Keep instructions consistent. Do not finish the patient's sentences, which adds frustration and discourages practice.

Speak in normal tones and avoid talking too fast. Give ample time to respond, and do not press for a response. Use gestures. Avoid "speaking down" or patronizing remarks. The patient is not necessarily hearing impaired, and raising your voice irritates. Forcing responses can trigger garbled or automatic speech. Intellectual ability often remains intact, so treat the patient as someone with value, competence, and intelligence.

Discuss familiar topics (weather, family, hobbies, jobs). This makes conversation meaningful and gives practice. Communicating during care doubles as social therapy and sustains the relationship.

Encourage SO to keep communicating with the patient, reading mail and discussing family events even if the patient cannot respond. This reduces isolation and maintains connectedness. Family and social support strongly influence the aphasic patient's quality of life.

Eliminate extraneous noise and stimuli. When communicating, cut background noise, keep eye contact, and hold your voice at a normal volume and rate. This reduces anxiety and the confusion of sensory overload.

Consult and refer to a speech therapist. A speech therapist assesses communication needs, identifies deficits, and recommends a method. Involve the patient in setting goals so strategies are individualized. A plan built with the speech therapist, neuropsychologist, and neurologist gives the best outcomes.

Arrange group, speech, and language therapy as indicated. Group therapy gives practice and reduces social isolation. Speech and language therapy is the mainstay for aphasia, individualized to the patient's deficits.

Provide information about melodic intonation. Musical ability is often spared in Broca aphasia, so the speech therapist has the patient express words with musical tones. This has shown promise in clinical trials.

4. Managing Post-Stroke Pain

Post-stroke pain is common and is often under-reported, diagnosed only when actively sought. Musculoskeletal pain is the most common, reported in up to 72% of stroke patients, and drives depression, anxiety, and sleep disorders that make rehabilitation harder.

Assess for shoulder stiffness and pain. Hemiplegic shoulder pain (HSP) affects the paralyzed side, with prevalence estimated at 25% to 50%. Altered movement patterns during motor recovery and neuropathic mechanisms (lower pain thresholds, allodynia, hyperpathia) contribute. HSP can keep the patient from learning new skills.

Assess for central poststroke pain (CPSP) syndrome. CPSP is pain and sensory abnormality in the body parts corresponding to the injured brain territory. It may be spontaneous or evoked and usually develops 3 to 6 months after a stroke, though latencies range from within a week to several years.

Assess for risk factors that contribute to pain. Female sex is an independent risk factor for post-stroke pain syndrome. Older age at onset predicts any pain syndrome, but younger patients are at higher risk for CPSP specifically. Peripheral vascular disease, prior alcohol and statin use, and a history of depression predict any post-stroke pain syndrome.

Assess for post-stroke headaches. Persistent post-stroke headache occurs around stroke onset and lasts more than 3 months, affecting 23% of patients. Risk factors include younger age, female sex, and pre-stroke primary headache disorder. New or worsening focal deficits with headache warrant repeat neuroimaging.

Recognize the need for a properly worn sling or orthoses. Strapping the hemiplegic shoulder prevents it from dangling and promotes normal scapular alignment. Shoulder orthoses reduce subluxation, but only while worn, and orthoses with both proximal and distal attachments work best.

Assist the patient when changing position. Never lift by the flaccid shoulder or pull on the affected arm, which causes pain. Use appropriate force when turning to avoid overstretching the shoulder joint, and support the affected extremity, since the arm's weight alone can cause subluxation.

Position the shoulder appropriately. Many shoulder problems are prevented by proper movement and positioning. Check the shoulder position when moving the patient and ensure the scapula glides forward, especially when lying on the hemiplegic side. Subluxation can result from incorrect sleeping postures, lack of support upright, or tension on the hemiplegic arm during transfers.

Move the arm slowly and rotate it outward when lifting. This avoids impingement. A paralyzed arm can sublux at the shoulder from gravity overstretching the capsule and musculature when the patient sits or stands early after a stroke. Elevate the arm and hand to prevent dependent edema, and use lap trays, pillows, and foam support.

Avoid overhead pulleys; use a shoulder sling for support. Pulling on the hemiplegic arm contributes to subluxation. Slings realign scapular symmetry, support the forearm, improve anatomic alignment, and support the shoulder with a cuff.

Perform ROM by holding the humerus under the axilla and maintaining external rotation. Incorrect handling causes improper motor control and rotator cuff tearing. Early passive ROM prevents shoulder subluxation. Shoulder ROM includes flexion-extension, abduction-adduction, and external-internal rotation, but improper technique can injure the shoulder.

Assist with range-of-motion exercises. ROM prevents shoulder stiffness and pain. The patient can interlace the fingers, place the palms together, and push the clasped hands forward to bring the scapulae forward, then raise both hands overhead; flex the affected wrist and move all finger joints; and push the heel of the hand firmly onto a flat surface.

Administer botulinum toxin A (BTX-A) as indicated. BTX-A provides greater analgesia and improves shoulder abduction and external rotation ROM compared with steroids. It is injected into the subscapularis and pectoralis major, the two most common spastic muscles in HSP, and a single intramuscular injection significantly reduces HSP at 3 and 6 months.

Administer oral pain medications as prescribed. Useful agents include amitriptyline, gabapentin, pregabalin, and lamotrigine. Lamotrigine has better evidence in CPSP, with a small trial showing significant pain reduction at 200 mg/day. Tramadol may help patients who do not respond to first-line agents.

Administer topical pain medications as indicated. Topical amitriptyline, ketamine, lidocaine, and capsaicin are used for localized neuropathic pain, with a lower side-effect profile than systemic therapy.

Promote exercise intervention programs. Exercise addresses pain, mobility, fatigue, and self-efficacy after stroke, and provides social participation linked to better self-management of chronic pain.

Educate family and caregivers on proper positioning and handling of the affected areas. Unsupported or mishandled arms raise the risk of traction neuropathy and injury, so caregivers must be trained to handle the hemiplegic arm, especially with subluxation present.

Teach the patient and family about shoulder strapping. Strapping helps in the first period after a stroke. The longitudinal method applies 2 to 3 strips with cephalad tension over the anterior, middle, and posterior deltoid; the circumferential method wraps around the shoulder joint from the clavicle, around the deltoid, under the axilla, ending on the spine of the scapula.

Provide instructions about the Bobath method. Bobath moves and positions the patient into reflex-inhibiting positions, keeping the hemiparetic limb away from abnormal increases in muscle tone.

Prepare the patient for neuromuscular electrical stimulation (NMES). NMES contracts and strengthens the supraspinatus and posterior deltoid fibers, important for glenohumeral stability. It reduces shoulder subluxation in the early post-stroke period (less than 6 months) but not the late period.

5. Promoting Effective Coping Strategies and Providing Emotional Support

Physical, social, and cognitive impairment after a stroke threatens quality of life. Coping style strongly shapes recovery and adaptation, so supporting effective coping is part of the work, not an afterthought.

Assess the extent of altered perception and the degree of disability. Determine the Functional Independence Measure (FIM) score. Individual factors shape the plan of care and discharge expectations. The FIM evaluates ADLs and compares rehabilitation outcomes, tracks progress, and guides treatment planning.

Identify the meaning of the dysfunction and change to the patient. Note the ability to understand events, and give a realistic appraisal. Independence is valued differently across cultures. Some patients adjust well; others struggle to recognize and accept deficits. Understanding what the stroke means to the patient lets you offer meaningful support and problem-solving.

Determine outside stressors: family, work, future healthcare needs. This identifies specific needs and starts problem-solving. Social factors and functional status are vital to discharge planning. In Framingham stroke survivors, 31% needed help with self-care, 20% needed help walking, and 71% had impaired vocational capacity in long-term followup.

Identify previous methods of dealing with problems. Determine support systems. This lets the patient build on past successes and mobilize resources. Active coping is linked to social support, and family support helps with disease management.

Monitor for sleep disturbance, difficulty concentrating, statements of inability to cope, lethargy, and withdrawal. These may signal depression, a common after-effect that needs evaluation. Around 30% of stroke survivors are estimated to experience depression, and a further 68% of carers experience depression or anxiety.

Note whether the patient calls the affected side "it" or denies it as "dead." This suggests rejection of the body part and negative body image, indicating a need for intervention and support. More than 6 months after an acute stroke, 85% of patients have upper-limb disorders from central nervous system changes plus disuse weakness.

Provide psychological support and set realistic short-term goals. Involve the SO in the plan of care and explain deficits and strengths. This builds confidence and compliance. Psychological support means communication, information, peer, and social support. Strengthening protective factors can reduce the need for formal psychological support.

Encourage the patient to express feelings, including hostility, anger, denial, depression, and disconnectedness. This shows acceptance and helps the patient deal with the feelings. Emotion-focused coping (regulating negative emotions) and accommodative coping (adjusting personal goals to deficits) help the patient cope.

Acknowledge feelings about the body's betrayal; stay matter-of-fact that the patient 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 shows you accept both sides as part of the whole person and lets the patient feel hopeful. Hospital-based peer support groups bring therapeutic gains: information, advice, connection, and social comparison.

Emphasize small gains in function or independence. This consolidates progress and reduces anger and helplessness. A flexible, accommodative coping style is associated with higher quality of life and better global wellbeing months after the event, as patients revise values, construct new meaning, and adjust goals.

Support behaviors such as increased interest and participation in rehabilitation. This suggests adaptation and understanding of one's role in future lifestyle. About 80% of stroke survivors are discharged home, many with disabilities severe enough to depend on practical and emotional support.

Refer for neuropsychological evaluation and counseling if indicated. Depression is common and may result directly from brain damage and from the emotional reaction to sudden disability. Psychological expertise is a vital part of the multidisciplinary stroke team.

Promote positive coping strategies. Active behavioral or emotional coping helps with stressful events. Responses that change the stressor improve daily activity, and both accommodative and active coping reduce depressive symptoms.

Prepare the patient for mirror therapy. Mirror therapy improves upper-extremity motor function and daily performance. It increases use of paralyzed limbs to overcome disuse, lets the patient observe and imitate movement, and changes the neural network involved in movement.

Provide information about peer support groups. Peer and social support are vital to post-stroke adjustment. Volunteer or family-led groups facilitate support, particularly for patients with lower-level psychological needs.

Provide hospital staff with resources to improve psychological management of post-stroke rehabilitation. Right information aids reassurance and adjustment. The Stroke Specific Education Framework gives staff competencies and training for psychological screening, assessment, and support, expanding the capacity of stroke services.

Educate the patient and family on what to expect during post-stroke rehabilitation. Information is a resource for empowerment and adjustment, and information provision post-stroke reduces patient depression, lowering the need for formal psychological support.

6. Promoting Independence Through Self-Care

Stroke hits motor control, mobility, ADLs, mood, speech, comprehension, and cognition. These deficits cut role fulfillment and quality of life, so rebuilding self-care is central to recovery.

Assess abilities and level of deficit (0 to 4 scale) for performing ADLs. This plans for individual needs. The FIM estimates functional independence across self-care, eating, grooming, bathing, dressing, toileting, swallowing, sphincter control, mobility, transfer, and locomotion.

Assess the patient's ability to communicate the need to void and to use a urinal or bedpan. Take the patient to the bathroom at intervals if appropriate. The patient may have a neurogenic bladder or be unable to communicate needs acutely but usually regains control as recovery progresses. About one-third of acute stroke patients have aphasia; at 6 months or more, only 12% to 18% still do.

Identify previous bowel habits and reestablish a normal regimen. Increase dietary bulk, encourage fluids, and increase activity. This builds a retraining program and prevents constipation and impaction. Brain injury, particularly stroke, is well established as a cause of GI disorders through the brain-gut axis.

Avoid doing things the patient can do, but assist as necessary. Doing as much as possible maintains self-esteem and promotes recovery. Patients may become fearful and dependent, so assistance prevents frustration while preserving autonomy and confidence.

Watch for impulsive actions suggesting impaired judgment. This may signal a need for added supervision and safety measures. Prefrontal cortex lesions impair decision-making and time processing.

Maintain a supportive, firm attitude. Allow enough time to accomplish tasks, and do not rush. Patients need empathy and consistent assistance. Difficulty perceiving body space impairs toileting and grooming, including washing, dressing, fastening clothes, and using zippers.

Provide positive feedback for efforts and accomplishments. This builds self-worth and independence. Engagement is co-constructed through relationships, and a positive connection gives the patient the courage and confidence to try.

Create a plan for visual deficits. Place food and utensils on the unaffected side, position the bed so the unaffected side faces the room with the affected side to the wall, and keep furniture against the wall and out of the path. This lets the patient see to eat and move safely, reducing tripping and falls.

Provide self-help devices: hooked extensions for picking things up, toilet risers, long-handled brushes, drinking straws, catheter leg bags, and shower chairs. Encourage grooming. These let the patient manage independently, build self-esteem, and stay socially active. Self-help devices improve upper-limb function, gait, and aphasia after stroke.

Encourage SO to let the patient do self-care as much as possible. This re-establishes independence and self-worth. It can be hard and frustrating for caregivers, but the relationship is a key source of motivation that moves the patient from tolerating therapy to engaging in it.

Teach the patient to comb hair, dress, and wash. This promotes independence and self-esteem. Guidelines recommend offering all patients training in self-management skills, including problem-solving and goal setting, to support the long-term consequences of stroke.

Refer to physical and occupational therapy. Rehabilitation relearns lost skills and teaches new ways to compensate for residual disability. In most reports, 47% to 76% of patients achieve partial or total independence in ADLs.

Educate the patient and family on self-management. Survivors and caregivers often feel unprepared for the hospital-to-community transition. The Look After Yourself (LAY) program teaches the five self-management skills: problem-solving, decision-making, resource use, partnership with professionals, and acting to manage health autonomously.

Refer for physical therapy. Therapy should target specific skill and functional training with enough intensity to drive skill acquisition, using ROM, strengthening, mobilization, compensatory techniques, and mental practice.

7. Preventing Dysphagia and Promoting Effective Swallowing

Stroke often causes dysphagia by impairing the mouth, tongue, and larynx. Dysphagia raises morbidity and mortality through malnutrition, dehydration, and aspiration pneumonia, so screen the swallow before anything goes in the mouth.

Review the pathology and ability to swallow: clarity of speech, tongue involvement, ability to protect the airway, coughing, and adventitious breath sounds. Assess the swallow before any oral intake. The NIHSS helps determine severity and location and flags a severe neurological deficit.

Maintain accurate I&O; record calorie count. Alternative feeding may be needed if swallowing cannot meet fluid and nutritional needs. Low nutritional status affects 8.2 to 49% of stroke patients, and dysphagia-modified diets like paste diets have fewer calories per volume.

Weigh periodically and monitor body mass index (BMI). Negative caloric intake after stroke worsens sarcopenia from paresis and reduced activity. Higher BMI is associated with better recovery and more autonomy in ADLs.

Keep suction equipment at the bedside, especially during early feeding. Timely suction limits the effects of aspiration. Aspiration pneumonia is the second most common complication after urinary tract infection in acute stroke and comes from aspiration of saliva with poor oral hygiene and food residue from poor swallowing.

Promote effective swallowing: schedule activities and medications to allow at least 30 minutes of rest before eating. This optimizes muscle function and limits fatigue. Rest lets the swallowing muscles recover their strength.

Provide a pleasant, unhurried environment free of distractions. This promotes relaxation and lets the patient focus on eating, easing the anxiety and stress of dysphagia and stimulating appetite.

Assist with head control and position based on the specific dysfunction. This counters hyperextension and prevents aspiration: head back for decreased posterior tongue propulsion, head turned to the weak side for unilateral pharyngeal paralysis, and lying on either side for reduced pharyngeal contraction.

Place the patient upright during and after feeding. This uses gravity to facilitate swallowing and reduce aspiration. Have the patient sit upright and tuck the chin toward the chest while swallowing.

Provide oral care based on individual needs before a meal. Dry mouths need alcohol-free moisturizing agents before and after eating; excessive saliva benefits from drying agents before meals and moisturizing afterward. Oral health affects aspiration pneumonia risk and oral intake.

Serve foods at normal temperature, and keep water chilled. Lukewarm temperatures stimulate salivation less. Water is the hardest to swallow, so serve it cold. Cold water stimulates oral temperature receptors and salivation.

Stimulate the lips to close or manually open the mouth by light pressure on the lips or under the chin if needed. This aids sensory retraining and muscular control. Lip force and swallowing function depend on the same neuromuscular activity.

Place food of appropriate consistency on the unaffected side of the mouth. This adds sensory stimulation, increasing salivation and triggering swallowing. Consistency depends on the deficit: decreased tongue range needs thick liquids first, progressing to thin; delayed pharyngeal swallow handles thick liquids and thicker foods better. Avoid pureed food, which patients may not recognize, and avoid milk products, peanut butter, syrup, and bananas, which produce mucus and are sticky.

Touch parts of the cheek with a tongue blade and apply ice to the weak tongue. This improves tongue movement and control and inhibits tongue protrusion. Tongue pressure drives bolus formation and transport, especially for semi-solid foods.

Feed slowly, allowing 30 to 45 minutes for meals. Feeling rushed raises stress, increases aspiration risk, and may end the meal early. Relaxation improves swallowing function.

Offer solid foods and liquids at different times. This prevents swallowing food before it is chewed. Offer liquids only after solids are finished to clear residual particles and reduce aspiration.

Limit or avoid drinking straws for liquids. Straws may strengthen facial and swallowing muscles, but if lip closure is poor or liquid lands too far back, aspiration risk rises. Straws can deliver liquid too fast for the swallowing mechanism.

Encourage SO to bring favorite foods. Season food with herbs, spices, or lemon juice to preference, within dietary restrictions. Familiar tastes stimulate feeding and may improve swallowing or intake, providing comfort and making meals more enjoyable.

Encourage participation in an exercise program. Exercise releases endorphins, boosts mood, reduces anxiety and depression, and increases appetite. Core and postural exercises promote proper head, neck, and trunk alignment for swallowing.

Administer IV fluids and tube feedings. These may be necessary if the patient cannot take anything orally. At discharge, the tube-feeding group tends to have worse general condition, since higher stroke severity brings greater weight loss from poor intake.

Coordinate a multidisciplinary approach. Dietitians and speech and occupational therapists increase the effectiveness of long-term plans and reduce silent aspiration. Speech-language pathologists are the experts in assessing and treating dysphagia.

Encourage frequent practice of swallowing exercises as directed by the speech therapist. Consistent practice drives adaptive brain changes, improves oral-motor coordination, and strengthens the swallowing muscles.

Promote deep breathing exercises. The patient takes a slow deep breath in, holds it a few seconds, then exhales, then practices inhaling deeply and quickly followed by exhaling slowly. Repeat each exercise 5 times.

Educate caregivers on safety precautions for dysphagia. Patients with dysphagia are at high risk of choking, so family and caregivers must know how to perform the Heimlich maneuver. If a patient cannot cough, talk, or breathe, they are choking. The Heimlich maneuver uses 5 back blows followed by 5 abdominal thrusts.

Prepare the patient for neurostimulation as indicated. Noninvasive neurostimulation promotes cortical reorganization to accelerate recovery in post-stroke dysphagia, delivered as peripheral or central stimulation.

8. Managing Fatigue and Tolerance to Activity

The main activity limitations after stroke are the inability to walk independently and difficulty with daily and self-care activities. Low physical activity raises the risk of recurrence, so build activity into rehabilitation.

Assess sleep patterns and note changes in thought processes and behaviors. Sleep deprivation, emotional distress, medication side effects, and disease progression all worsen fatigue. Post-stroke fatigue includes overwhelming tiredness, an abnormal need for naps or extended sleep, tiring more easily than before, and unpredictable fatigue without apparent reason.

Assess the extent to which the patient can perform ADLs. Recovery may require many adaptive changes and family assistance. The type and degree of disability depend on which area of the brain is damaged.

Assess the level of fatigue and evaluate other causes. Post-stroke fatigue (PSF) is an overwhelming exhaustion unrelated to exertion that does not improve with rest. It is linked to undesirable outcomes and affects participation, medication adherence, and rehabilitation effectiveness.

Use valid, reliable tools to identify fatigue levels. The Fatigue Severity Scale (FSS) is the main measure in observational studies, and the Fatigue Assessment Scale (FAS) is used most in interventional studies. Both are valid and reliable; FSS is favored for comparability across studies.

Assess for post-stroke depression. Fatigue and depressive symptoms co-exist in up to 30% of survivors. Depression in mild cognitive impairment (MCI) runs about 32%, and patients with depression may progress faster from MCI to dementia. These conditions delay recovery.

Schedule activities for periods of most energy and adjust as needed. This prevents overexertion. Pacing and spreading activities with rests is a helpful fatigue management strategy: a single activity in the day, with little else on either side of it.

Encourage the patient to do whatever is possible. This provides control and accomplishment. Self-efficacy, the belief in one's capability to act, adds energy: the stronger the conviction, the higher the goals and commitment despite adversity.

Instruct the patient, family, or caregiver in energy conservation. This conserves limited energy and limits fatigue. Structure the day to balance activity and rest, anticipate energy needs, prioritize high-value activities, and delegate low-priority tasks to family.

Plan visits around the patient's increased sleep and shorter periods of alertness. The patient tires easily and sleeps more, and may have periods of unresponsiveness, confusion, or a dream state that can distress visitors. Patients often need sleep to manage PSF and feel they will crash without it.

Demonstrate proper performance of ADLs, ambulation, and position changes. This protects the patient and caregiver from injury. Teach the patient to sit rather than stand for chores like washing dishes or ironing, and to use proper body mechanics and posture.

Encourage nutritional intake and supplements as appropriate. Some survivors report that diet changes improved how they felt, whether to lose weight or improve general health.

Provide information about cognitive behavioral therapy (CBT) and other psychotherapies for PSF. In a 12-week program, 83 participants with severe fatigue 4 months post-stroke received group cognitive treatment alone or combined with graded activity training. Those treated were significantly more likely to have clinically relevant improvement in fatigue severity.

Promote good sleep hygiene. Counsel the patient and family on good sleep hygiene and avoiding sedating drugs and excessive alcohol. Hypersomnia and excessive daytime sleepiness affect 27% of patients, while insomnia affects 57% in the early months.

Encourage relaxation or meditation exercises. Some patients find meditative activities a beneficial fatigue management strategy, whether through apps and websites or quiet time spent recharging.

Promote the use of a fatigue diary. A diary helps plan daily and weekly activities and identify triggers. Caregivers use it to record key events and review which activities induce fatigue.

Administer medications as indicated. Agents evaluated for PSF include selective serotonin reuptake inhibitors (fluoxetine) and modafinil. Modafinil, used for hypersomnia and narcolepsy, relieves PSF better in brainstem-diencephalic strokes than cortical strokes. A trial found fluoxetine ineffective for PSF, though it improved depression.

9. Assessing and Monitoring for Unilateral Neglect

Unilateral spatial neglect (USN) is failure to react to stimuli from the side opposite a brain lesion, with no other sensory or motor deficit. About 80% of patients with right hemisphere injury from acute stroke show USN. It may improve during rehabilitation but usually persists.

Assess for signs of unilateral neglect. Signs and symptoms include:

• Neglecting to wash, shave, or dress one side of the body
• Sitting or lying on the affected arm or leg
• Failing to respond to environmental stimuli contralateral to the lesion
• Eating food on only one side of the plate
• Failing to look to one side of the body
• Altered safety behavior on the neglected side
• Disturbed sound lateralization
• Failure to dress the neglected side
• Failure to eat food from the neglected side of the plate
• Failure to groom the neglected side
• Failure to move body parts (eyes, head, limbs, trunk) into the neglected hemisphere
• Failure to notice people approaching from the neglected side
• Hemianopsia

Patients with USN need careful monitoring for difficulty with self-care like eating and dressing, plus the risk of falls.

Progressively build the patient's ability to cope with neglect using assistive devices, feedback, and support during rehabilitation. Recovery from neglect mostly happens in the first 4 weeks, then slows. Rehabilitation is broadly top-down (encouraging attention to the neglected side) or bottom-up (activating higher-order central nerves through peripheral stimulation).

Initiate fall prevention. Patients with CVA are twice as likely to fall. Keep the environment safe and clear of hazards, and place visual cues such as brightly colored objects, signs, or pictures on the neglected side.

Set up the environment so essential activity is on the unaffected side. Place personal items within view on the unaffected side and position the bed so the patient is approached from that side, which raises awareness and promotes interaction. At discharge, arrange the home environment to minimize ADL impairment from neglect.

Teach the patient to turn the head toward the defective visual field. This compensates for lost visual acuity. Encourage active scanning by turning the head and eyes to both sides, with verbal or visual cues to check the neglected side, improving attention and reducing falls.

Teach the patient to be aware of the problem and modify behavior and environment. Awareness reduces injury risk. At home, position the bed so the patient gets out on the unaffected side. Sustained attention training with auditory feedback and visual scanning helps the patient recognize the deficit.

Encourage family participation in care and exercise. Patients improve more with family involvement. A group doing family-participation self-training for about 3 weeks improved in transfer and mobility, unlike the group without family participation.

Teach the patient to scan body part positions and to turn the head side to side when ambulating or doing ADLs. This increases safety. Saccadic compensation and visual scanning training improve a quick, safe visual overview of a scene.

Speak in a calm, comforting, quiet voice using short sentences. Maintain eye contact. The patient may have a limited attention span or comprehension problems. A calm voice helps them focus and direct attention toward the speaker.

Ascertain the patient's perceptions. Reorient frequently to the environment, staff, and procedures. This helps the patient identify inconsistencies in stimuli and reduces perceptual distortion. Reorientation builds awareness of surroundings, including the neglected side.

Approach the patient from the visually intact side. Leave the light on, position objects in intact visual fields, and patch the affected eye if indicated. This helps the patient recognize people and objects and avoids startling them. A half-opaque eye patch improves visuospatial attention by masking the view of the normal side.

Stimulate the sense of touch. Give objects to touch and hold, and have the patient touch walls and boundaries. This retrains sensory pathways and helps the patient orient spatially and use the affected side. Provide tactile cues on the neglected side and have the patient explore textures like fabric, sandpaper, or different surfaces with the neglected hand.

Encourage the patient to watch their feet and consciously position body parts. Visual and tactile stimuli reintegrate the affected side and reawaken forgotten sensations of normal movement. Sustained attention training raises arousal and improves cancellation test performance.

Provide information about mirror therapy. The patient places both arms on a table with a mirror between them, looks in the mirror, and moves both arms, with the reflecting side facing the non-affected arm. Mirror therapy significantly affects spatial neglect.

Prepare the patient for transcutaneous electrical nerve stimulation (TENS). TENS of the posterior sternocleidomastoid improves postural control in neglect. Combined with visual scanning training, it improves neglect tests and reading and writing tasks.

10. Assessing and Monitoring for Disuse Syndrome

Stroke-related sarcopenia (loss of skeletal muscle mass and strength) raises the risk of falls, fractures, longer hospitalization, disability, and mortality, and reduces treatment effect and quality of life. Prevent the secondary damage that immobility causes.

Assess for subluxation of the shoulder: severe pain and swelling, tingling, inability to move the joint, and altered appearance of bony prominences. Subluxation happens when the shoulder muscles weaken and the joint separates. Use the fingerbreadth palpation method, comparing the unaffected and affected sides with the patient seated, feet flat, shoulders in neutral rotation, and the arm hanging close to the body with no abduction.

Assess for unilateral spatial neglect. Neglect often shows in behavior before a conclusive diagnosis, with a clear lack of awareness of the affected side. Tests include line bisection, single letter cancellation, clock drawing, and behavioral inattention.

Instruct the patient to inspect their extremities and check position before ambulating. These are safety precautions against falling. Alert the patient to consciously raise and extend the foot when ambulating, reinforced through verbal, video, and visual feedback training.

Provide a pillow or lapboard to support correct alignment. These maintain anatomic position. Lap trays, pillows, and foam support keep the arm and shoulder supported, reducing strain on the ligaments and preventing a frozen shoulder.

Instruct the patient with balance problems to lean toward the stronger side for correct upright posture. Stroke patients tend to lean on the weak side. About 83% of survivors have balance impairment, marked by short supporting time, side-to-side differences, and slow walking speed, which raises fall risk.

Encourage use of an arm sling. The sling supports and protects the arm and shoulder while standing or ambulating. Slings realign scapular symmetry, support the forearm, improve anatomic alignment, and support the shoulder with a cuff.

Avoid pulling the affected arm. Place a hand behind the scapula when moving the upper extremity instead of pulling from the arm. Use a lift sheet during repositioning. When sitting, give the arm a firm support surface. These prevent subluxation and deformity. In bed, place the shoulder slightly forward to counter rotation, and place the affected arm in external rotation when lying on the affected side.

Teach transfer techniques using the stronger extremity to move the weaker one. To move the affected leg or change from lying to sitting, slide the unaffected foot under the affected ankle to lift and bring the affected leg along. Use proper body mechanics, and never pull on the affected arm or grab under the shoulder or armpit, which causes pain and lasting complications.

Instruct the patient to use proper footwear and avoid slippers. Well-fitting footwear improves balance; slippers raise fall risk. Inappropriate footwear, whether unsafe features or incorrect size, is associated with falls, and tread design affects friction and slipping.

Provide light joint ROM exercises and proper arm positioning to avoid shoulder-hand syndrome. Encourage repeated shoulder movement and fist clenching and unclenching. Shoulder-hand syndrome is a neurovascular condition with pain, edema, and skin and muscle atrophy from impaired circulatory pumping of the upper extremity. Early passive ROM (flexion-extension, abduction-adduction, external-internal rotation) prevents subluxation.

Apply these transfer principles:

• Encourage weight bearing on the stronger side.
• Teach the patient to focus on the stronger side and use the stronger arm for support.
• The simplest and safest transfer is toward the unaffected side.
• Put the unaffected side closest to the bed or chair the patient transfers to.
• Place the affected leg under, with the foot flat on the ground, during transfer.
• Place a locked wheelchair or braced chair near the stronger side.

These use the stronger side to support safe transfers and reduce falls. Train the patient, family, and caregiver in safe transfer and mobility techniques to increase safety, confidence, and independence.

If the patient needs help from staff, keep them from pulling on or putting hands around the assistant's neck. Staff should brace the patient's feet and knees with their own, stand close to avoid overreaching, keep the shoulders neutral, tighten the abdominal muscles, and use a wide base of support for balance.

Refer to physical and occupational therapy if needed. Reinforce mobilization techniques such as proprioceptive neuromuscular rehabilitation, neurodevelopmental treatment, motor relearning, and constraint-induced movement therapy per the individualized plan. Bobath uses the affected side in mobility training so the patient bears weight on it and relearns normal patterns. Constraint-induced therapy restrains the functioning arm to drive rewiring and improve functional movement. Action observation training and mirror therapy increase use of paralyzed limbs to overcome disuse.

Provide instructions about mirror therapy. Mirror therapy improves upper-extremity motor function and daily activity, though conventional methods require high concentration. Mirror therapy with a gesture recognition device has a positive effect on motor function and quality of life in chronic stroke.

11. Promoting Safety and Preventing Injuries

Of the estimated 800,000 strokes per year in the US, most survivors develop long-term functional deficits. Motor recovery is a complex, multifactorial process, and your job is to prevent the falls, burns, and injuries that derail it.

Assess the type and degree of hemisphere injury. A left-brain stroke affects the right side of the body, producing right-sided paralysis, speech and language problems, a slow cautious style, and memory loss. A right-brain stroke affects the left side, producing left-sided paralysis, vision problems, a quick inquisitive style, and memory loss.

Evaluate for visual deficits: visual field loss, changes in depth perception, and diplopia (double vision). Visual disorders impair the patient's ability to perceive the environment and relearn motor skills, raising the risk of injury. Neglect or spatial inattention is not a vision problem but results from damage to the parts of the brain that interpret vision.

Assess sensory awareness: dull from sharp, hot from cold, body part position, and joint sense. Diminished sensation and kinesthetic impairment hurt balance, positioning, and movement, raising the risk of trauma. Somatosensory impairment affects tactile sensation, vibration, pressure, proprioception, temperature, and pain.

Note inattention to body parts, segments of the environment, and lack of recognition of familiar objects or persons. Agnosia, the loss of comprehension of sensations, can lead to unilateral neglect, self-care deficits, and disorientation. With neglect, the brain does not process information from the affected side efficiently.

Encourage patients with non-dominant (right) hemisphere injury to slow down and check each step. These patients may have decreased pain sensation and visual field deficits but are typically unaware of or deny their deficits. They are impulsive, overestimate their abilities, and are at risk for burns, bruises, cuts, and falls, sometimes needing to be restrained from unsafe activities. They are more likely to have unilateral neglect.

Remind patients with dominant (left) hemisphere injury to scan their environment. These patients may lack pain sensation and position sense and have right-sided visual field deficits but usually do not show neglect. Visual scanning training, the most common method, reduces unilateral neglect.

Encourage a conscious effort to scan the environment by turning the head side to side. The patient may have homonymous hemianopsia, seeing only part of the normal field. Top-down training includes sustained attention training with auditory feedback and visual scanning, which require the patient to be aware of the symptoms and actively attend.

Give short, simple messages and step-by-step directions. Keep it concrete (say "water," not "fluid"; "leg," not "limb"). These patients may have poor abstract thinking and are slow, cautious, and disorganized with unfamiliar problems, benefiting from frequent, accurate, immediate feedback. Vascular dementia associated with left-hemisphere stroke impacts reasoning, planning, judgment, and memory.

Have patients with apraxia return your demonstration of a task, or see if they can be talked through it or talk themselves through it step-by-step. Use evidence-based methods like teach-back, which improves disease-specific knowledge, adherence, and self-efficacy, and reduces unplanned 30-day readmissions.

Keep the environment simple to reduce sensory overload and aid concentration on visual cues. Remove distracting stimuli. The patient may not recognize objects by hearing, vibration, or touch and relies on visual cues. At discharge, arrange the home to minimize ADL impairment from neglect and explain the symptoms to the family.

Assist with eating. Monitor for safety hazards and remove dangerous objects such as scissors from the bedside. The patient may not recognize familiar objects or their purpose, and may not detect subtle differences (a fork versus a spoon). Cognitive deficits include difficulty solving problems, dementia, memory problems, and communication challenges.

Teach the patient to concentrate on body parts, such as watching the hands sway or the feet move while walking. A mirror can help them adjust. The patient may misperceive their own body and not perceive a foot or arm as part of it. In mirror therapy, the paralyzed parts are covered with a mirror placed at the center of the body, giving the visual illusion that the paralyzed side is moving normally.

Provide a restraint or wheelchair belt for support. The patient may be unable to orient in space and may not know if they are standing, sitting, or leaning. Patients with neglect need monitoring for self-care difficulty and the fall and fracture risk that comes with transfers and walking.

Provide a structured, consistent environment. Mark the outer aspect of the shoes or tag inside the sleeve of a sweater or pants with "L" and "R." The patient may have a visual-spatial misconception, misjudging distance, size, position, rate of movement, and form. They may underestimate distances and bump into doors, confuse the inside and outside of clothing, or lose their place when reading or adding numbers.

Direct the patient's attention to a particular sound (playing different musical instruments and associating each sound with its name). The patient may be unable to recognize or interpret sounds and may be highly sensitive to sound, a common side effect called auditory overload when the brain cannot keep up with sensory input.

Protect from temperature extremes and assess the environment for hazards. Recommend testing warm water with the unaffected hand. This reduces injury risk. Sensory issues after a stroke take many forms, including numbness on the affected side and trouble distinguishing hot from cold or light from deep pressure.

Assist during sensory retraining exercises. Sensory reeducation retrains the brain to process sensory signals, promoting the return of sensation. Consistent practice drives neuroplasticity by stimulating sensory processing.

Educate the patient and caregivers on continuing sensory retraining at home. The patient can do sensory exercises at home at least 10 times for about 10 to 15 minutes a day, including tabletop touch therapy with various textures and temperature differentiation with hot and cold materials to rewire neural pathways.

12. Initiating Patient Education and Health Teachings

Right information aids reassurance and adjustment, and information provision post-stroke reduces patient depression. Good teaching lowers the need for formal psychological support, so make it part of the plan.

Assess the type and degree of sensory-perceptual involvement. This shapes teaching methods and content complexity. Vascular cognitive impairment most often affects attention, processing speed, and frontal-executive functions like planning, decision-making, judgment, error correction, and holding and manipulating information.

Identify signs and symptoms requiring further followup: decline in visual, motor, or sensory function; altered mentation or behavior; severe headache. Prompt evaluation reduces complications and further loss of function. Screen stroke and TIA patients for vascular cognitive impairment before discharge, during inpatient rehabilitation, and at post-stroke followup.

Identify individual risk factors (hypertension, cardiac dysrhythmias, obesity, smoking, heavy alcohol use, atherosclerosis, poor diabetes control, oral contraceptive use) and discuss lifestyle changes. This may reduce recurrence. Obesity in women correlates highly with ischemic stroke. Modifiable risk factors cause more than 90% of the stroke burden, and more than 75% could be reduced by controlling metabolic and behavioral factors.

Assess the patient's and family's health literacy. Effective education starts with their capacity to obtain, process, and understand health information, delivered meaningfully and at the right level. Validated tools include the Rapid Assessment of Adult Health Literacy in Medicine, the Test of Functional Health Literacy in Adults, and the Newest Vital Sign.

Include SO and family in discussions and teaching. They provide support and care, shaping the patient's quality of life and home care. The discharge transition from inpatient to home is one of the most vulnerable events in the continuum of care.

Discuss specific pathology and individual potentials. This sets realistic expectations. Top educational needs identified by survivors include stroke signs, symptoms, and prevention; treatment and medications; recovery and return to work; causes of stroke; and physical care including transfers, lifting, and personal care.

Review current restrictions and the potential resumption of activities, including sexual relations. This provides hope and the expectation of a more normal life. The most critical educational needs relate to functional needs, activity and participation, and environmental concerns.

Reinforce the therapeutic regimen, including medications to control hypertension, hypercholesterolemia, and diabetes; and aspirin or similar drugs such as ticlopidine and warfarin sodium. Identify ways to continue after discharge. Establish activities, limitations, and medication and therapy needs through a coordinated interdisciplinary approach. Long-term anticoagulation may benefit patients older than 45 who are prone to clot formation, but is not practical for CVA from vascular aneurysm or vessel rupture.

Provide written instructions and schedules for activity, medication, and essential facts. This reinforces teaching after discharge. Written prescriptions for exercise and smoking-cessation medications increase the likelihood of success.

Encourage the patient to use written notes instead of relying on memory. This supports memory and improves cognitive skills. The AHA/ASA series Let's Talk about Stroke offers downloadable, standardized education that providers can use consistently across care settings.

Discuss plans for meeting self-care needs. Varying levels of assistance may be planned for. Self-management is now part of the stroke care pathway and supports patients facing the long-term consequences of stroke.

Suggest reducing environmental stimuli, especially during cognitive activities. Multiple stimuli aggravate confusion and impair mental ability. Cognitive rehabilitation targets attention, memory, and executive function. Enriched environments improved working memory but not attention.

Recommend seeking assistance in problem-solving and validating decisions as indicated. Some patients, especially with right CVA, show impaired judgment and impulsivity. Executive function deficits may be treated with metacognitive strategy training and formal problem-solving strategies under a trained therapist, plus internal strategy training for goal management, time management, and metacognitive reasoning.

Review the importance of a balanced diet, low in cholesterol and sodium if indicated. Discuss vitamins and supplements. This improves general health and provides energy. Adherence to overall dietary patterns is increasingly associated with cardiovascular health and stroke risk.

Reinforce the importance of followup care by rehabilitation teams: physical, occupational, vocational, and speech therapists, and dieticians. Consistent work can minimize or overcome residual deficits. Advanced practice nurse-led transitional care models reduce readmissions through followup calls, home and clinic visits, identification of patient goals, education, medication reconciliation, and handoff to the primary care provider.

Refer to a home care supervisor or visiting nurse. The home may need evaluation and modification. A seamless transition requires clear, frequent communication between the interprofessional team and the case manager, identifying barriers to a safe transition home and modifying the plan as data come in.

Provide accessible, reliable community resources. Connecting patients and caregivers to community resources is key to a smooth transition home. The most commonly needed resources include outpatient therapies, home-delivered meals, transportation, financial assistance, help with household tasks, community exercise programs, and support groups.

Use evidence-based methods of health education. Teach-back and health coaching optimize knowledge and outcomes. Health coaching partners with patients and caregivers to set recovery goals, develop problem-solving skills, and improve confidence, which improves post-discharge outcomes.

Address the needs of family caregivers. Assess caregivers for their commitment and capacity to provide care, especially for the transition home. Base discharge plans on the caregiver's preparedness as well as the patient's needs, since caregivers often feel overwhelmed and unprepared.

Strengthen healthcare staff knowledge about stroke and post-stroke care. Helping survivors and caregivers across care settings requires specific nursing knowledge and skills. Nurses must know current stroke guidelines, use nursing resources, and share resources with patients and family caregivers.

13. Administer Medications and Provide Pharmacologic Support

Thrombolytics: tissue plasminogen activator (tPA), recombinant tPA (rt-PA). Given with an anticoagulant to treat ischemic stroke. tPA converts plasminogen to plasmin, dissolving the clot blocking blood flow. Fibrinolytic therapy given 3 to 4.5 hours after symptom onset improved neurologic outcomes in ECASS III, supporting a wider time window in carefully selected patients. Give it intravenously (or intra-arterially) as soon as ischemic stroke is confirmed, and monitor for bleeding. Thrombolytics are contraindicated in hemorrhagic stroke.

Anticoagulants: warfarin sodium, low-molecular-weight heparin. Given to prevent extension of the clot and formation of new clots and to improve cerebral blood flow. They do not dissolve an existing clot. Patients with embolic stroke and another indication for anticoagulation may be anticoagulated nonemergently to prevent further embolic disease, weighed against the risk of hemorrhagic transformation. Never give anticoagulants in hemorrhagic stroke.

Antiplatelet agents: aspirin, dipyridamole, ticlopidine. Daily low-dose aspirin interferes with platelet aggregation and can reduce cerebral infarction in patients who have had TIAs from embolic or thrombotic stroke. AHA/ASA guidelines recommend aspirin 325 mg orally within 24 to 48 hours of ischemic stroke onset. These are contraindicated in hypertensive patients because of the increased risk of hemorrhage.

Antifibrinolytics: aminocaproic acid. Used with caution in hemorrhagic disorders to prevent lysis of formed clots and rebleeding. Fibrinolytics restore cerebral blood flow in some patients with acute ischemic stroke but may cause symptomatic intracranial hemorrhage.

Antihypertensives: ACE inhibitors, diuretics. Used in patients undergoing fibrinolytic therapy, where blood pressure control is essential to reduce bleeding risk. For patients who are not fibrinolysis candidates, the 2013 ASA guideline thresholds for treatment are systolic blood pressure higher than 200 mm Hg or diastolic above 120 mm Hg, with a reasonable goal of lowering blood pressure by 15% during the first 24 hours. Antihypertensives are also used for secondary stroke prevention.

Peripheral vasodilators: nitroprusside sodium. Transient hypertension often occurs during an acute stroke and usually resolves without intervention. Vasodilators improve collateral circulation or decrease vasospasm by direct vasodilation and relaxation of vascular smooth muscle.

Neuroprotective agents: excitatory amino acid inhibitors and gangliosides. Reducing the release of excitatory neurotransmitters in the ischemic penumbra may improve neuron survival, but no single neuroprotective agent has yet been supported by randomized, placebo-controlled human studies.

Anticonvulsants: phenytoin and phenobarbital; benzodiazepines: diazepam, lorazepam. Agents used for recurrent convulsive seizures are also used for seizures after a stroke. Benzodiazepines, typically diazepam and lorazepam, are first-line for ongoing seizures. Diazepam controls active seizures and should be augmented by longer-acting anticonvulsants such as phenytoin or phenobarbital.

Stool softeners. These prevent straining during bowel movements and the corresponding rise in ICP. Constipation frequently follows a stroke because patients reduce mobility, fluid, and fiber intake, may have difficulty swallowing, and depend on others for toileting.

Administer insulin therapy as indicated. Maintain tight blood sugar control with insulin, aiming for normoglycemia (90 to 140 mg/dL), and monitor closely throughout hospitalization to avoid hypoglycemia.

14. Monitoring Results of Diagnostic and Laboratory Procedures

Monitor laboratory studies as indicated: prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level. These show drug effectiveness and therapeutic level. Coagulation studies may reveal a coagulopathy and are useful when fibrinolytics or anticoagulants are used. In patients not taking anticoagulants or antithrombotics and with no suspicion of coagulation abnormality, do not delay rt-PA while awaiting results.

Monitor the computed tomography scan. CT is the initial diagnostic test, performed immediately on presentation to the emergency department, and determines whether the event is ischemic or hemorrhagic to guide therapy. CT angiography (CTA) detects intracranial occlusions and their extent. Speed is critical because of the narrow window for definitive ischemic stroke treatment with pharmacologic agents and mechanical devices.