Nursing Care Plan Sample: Patient Following a Stroke

Model Answer

Patient Scenario

Mr R, a 67-year-old man, was brought to the emergency department by ambulance after his wife noticed sudden facial drooping, slurred speech and weakness of his right arm while eating breakfast. Time of onset was established as approximately 40 minutes before arrival. A Face, Arm, Speech, Time (FAST) assessment was positive, and an urgent CT scan confirmed an acute ischaemic stroke affecting the left middle cerebral artery territory, with no evidence of haemorrhage. He received intravenous thrombolysis within the recommended window and was admitted to the hyperacute stroke unit for ongoing monitoring and rehabilitation. His past medical history includes hypertension, atrial fibrillation for which he had been prescribed but had stopped taking apixaban six months earlier due to a fall, and type 2 diabetes. On admission to the ward he presented with dense right-sided weakness affecting the arm more than the leg, expressive dysphasia making word-finding difficult, and mild dysphagia noted on initial swallow screening.

His wife, present throughout, reported that Mr R had been independent in all activities of daily living prior to this event, worked part-time, and was an active member of a local walking group. This baseline functional status is important in care planning, as rehabilitation goals are set relative to his prior independence rather than to a generic standard, and his engaged, motivated personality is a resource to be built upon in his recovery plan. The circumstance of his apixaban discontinuation, a decision made independently after a minor fall without medical review, is also directly relevant: it represents a modifiable contributor to this stroke and will need sensitive, structured discussion as part of secondary prevention before discharge, rather than simply resuming the medication without addressing his underlying fear of bleeding risk.

Mr R and his wife were understandably distressed at the sudden onset of his symptoms, and his wife described feeling frightened by his difficulty finding words, having initially mistaken it for confusion rather than a language deficit. She was closely involved from the outset in providing collateral information and later in supporting his communication, and staff were mindful throughout of explaining his condition clearly to both of them, recognising that expressive dysphasia can easily be misread by unfamiliar visitors or staff as a global cognitive problem when in fact his understanding remained largely intact.

Assessment

Assessment combined a structured Airway, Breathing, Circulation, Disability, Exposure (A–E) survey with the Activities of Living model of Roper, Logan and Tierney (2000), alongside stroke-specific validated tools, consistent with the Nursing and Midwifery Council Code (2018) and the Royal College of Physicians’ National Clinical Guideline for Stroke.

Airway/Breathing: airway patent but at risk given dysphagia; respiratory rate and oxygen saturations within normal limits; nil-by-mouth pending formal swallow assessment. Circulation: irregularly irregular pulse at 88 bpm consistent with known atrial fibrillation, blood pressure 162/94 mmHg, managed cautiously per acute stroke blood-pressure guidance rather than aggressively lowered. Disability: National Institutes of Health Stroke Scale (NIHSS) score of 9 on admission, indicating moderate stroke severity; Glasgow Coma Scale 15/15; dense right arm weakness (Medical Research Council grade 2/5), moderate right leg weakness (grade 3/5), expressive dysphasia. Exposure: skin intact, no pressure damage, though immobility and sensory changes on the right side raise future risk.

A validated bedside swallow screen identified signs of aspiration risk, prompting nil-by-mouth status and urgent referral to speech and language therapy for formal assessment, in line with national stroke standards recommending screening within four hours of admission (Royal College of Physicians, 2016). A Waterlow pressure ulcer risk assessment scored him at high risk owing to reduced mobility and sensory impairment, and a falls risk assessment similarly identified him as high risk given unilateral weakness and unfamiliar surroundings. His mood and cognition were screened using brief validated tools appropriate to his dysphasia, noting some frustration consistent with communication difficulty rather than clear evidence of depression at this early stage, flagged for ongoing monitoring. Multidisciplinary input from physiotherapy, occupational therapy and speech and language therapy was requested within 24 hours of admission, in keeping with the recommended hyperacute stroke unit staffing and assessment standards (Royal College of Physicians, 2016; NICE NG128, 2022).

Nursing Diagnoses

Four prioritised nursing diagnoses were identified, ranked by immediacy of risk to safety and recovery:

1. Impaired swallowing related to right-sided neurological deficit, evidenced by an abnormal bedside swallow screen and clinical signs of aspiration risk (actual problem, highest priority).

2. Impaired physical mobility related to right-sided hemiparesis, evidenced by Medical Research Council grades 2/5 (arm) and 3/5 (leg) and a high falls risk score (actual problem, high priority).

3. Impaired verbal communication related to expressive dysphasia, evidenced by observed word-finding difficulty and reported frustration (actual problem, high priority).

4. Risk of recurrent stroke related to previously discontinued anticoagulation and unmanaged atrial fibrillation, evidenced by his history of stopping apixaban and confirmed atrial fibrillation on admission (risk problem, medium priority but essential to secondary prevention).

The first three diagnoses reflect immediate safety and functional priorities within the hyperacute phase, while the fourth, though lower in immediate physiological urgency, is prioritised for early, sensitive discussion because delay increases the window of recurrent stroke risk (Royal College of Physicians, 2016; NICE NG128, 2022).

The Care Plan

Evaluation and Review

Evaluation was undertaken at each nursing handover and formally reviewed at the weekly multidisciplinary team meeting, using the NIHSS trend, swallow status, Medical Research Council grading, communication progress and Mr R’s own reported goals as markers of progress, consistent with a person-centred, standards-aligned approach (NMC, 2018; Royal College of Physicians, 2016). Where goals were only partially met, for example if swallow function remained impaired beyond the expected timeframe, the plan specified continued nil-by-mouth status with alternative nutrition and closer speech and language therapy involvement rather than a premature return to oral intake. Discharge planning was integrated from early in the admission, involving the multidisciplinary stroke team, the early supported discharge service and, with Mr R’s consent, his wife, to ensure rehabilitation continued safely at home.

By day seven, Mr R’s swallow had improved sufficiently to permit a modified-consistency diet under speech and language therapy guidance, his right arm power had improved to grade 3/5 and his leg to grade 4/5, allowing supervised mobilisation with a stick, and his communication had progressed such that he could construct short sentences with occasional word-finding support. No falls occurred during the admission. Following a sensitive, structured conversation with the stroke specialist nurse, Mr R agreed to restart anticoagulation with a clear falls-mitigation plan in place, and he correctly repeated back the rationale and warning signs using teach-back. A discharge planning meeting agreed referral to the early supported discharge team for continued physiotherapy, occupational therapy and speech and language therapy at home, with a stroke specialist nurse follow-up within one week. His wife was given contact details for a local stroke support group and written information on communication strategies, reflecting the wider recognition that family carers require their own support and education to sustain recovery once formal input reduces in the community. This evaluation demonstrates the cyclical, multidisciplinary nature of stroke nursing care: assessment findings shaped diagnoses, diagnoses shaped goals and interventions, and evaluation against those goals in turn informed both the ongoing plan and a safe, rehabilitation-focused discharge (Roper, Logan and Tierney, 2000; NMC, 2018).

References

National Institute for Health and Care Excellence (2022) Stroke and Transient Ischaemic Attack in Over 16s: Diagnosis and Initial Management (NG128). London: NICE.
National Institute for Health and Care Excellence (2023) Stroke Rehabilitation in Adults (NG236). London: NICE.
Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
Roper, N., Logan, W.W. and Tierney, A.J. (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Churchill Livingstone.
Royal College of Physicians (2016) National Clinical Guideline for Stroke. London: RCP.
Stroke Association (2021) Communicating With People Affected by Stroke: A Guide for Health Professionals. London: Stroke Association.