Ischemic Stroke Nursing Diagnosis :
- Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
- Acute pain (painful shoulder) related to hemiplegia and disuse
- Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae
- Disturbed sensory perception related to altered sensory reception, transmission, and/or integration
- Impaired swallowing
- Total urinary incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating
- Disturbed thought processes related to brain damage, confusion, or inability to follow instructions
- Impaired verbal communication related to brain damage
- Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility
- Interrupted family processes related to catastrophic illness and caregiving burdens
Hemorrhagic Stroke Nursing Diagnosis:
- Ineffective tissue perfusion (cerebral) related to bleeding or vasospasm
- Disturbed sensory perception related to medically imposed restrictions (aneurysm precautions)
- Anxiety related to illness and/or medically imposed restrictions (aneurysm precautions)
Altered Level of Consciousness Nursing Diagnosis
- Ineffective airway clearance related to altered LOC
- Risk of injury related to decreased LOC
- Deficient fluid volume related to inability to take fluids by mouth
- Impaired oral mucous membrane related to mouth-breathing, absence of pharyngeal reflex, and altered fluid intake
- Risk for impaired skin integrity related to immobility
- Impaired tissue integrity of cornea related to diminished or absent corneal reflex
- Ineffective thermoregulation related to damage to hypothalamic center
- Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control
- Bowel incontinence related to impairment in neurologic sensing and control and also related to changes in nutritional delivery methods
- Disturbed sensory perception related to neurologic impairment
- Interrupted family processes related to health crisis
Patient with Increased Intracranial Pressure Nursing Diagnosis
- Ineffective airway clearance related to diminished protective reflexes (cough, gag)
- Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement)
- Ineffective cerebral tissue perfusion related to the effects of increased ICP
- Deficient fluid volume related to fluid restriction
- Risk for infection related to ICP monitoring system (fiberoptic or intraventricular catheter)
Craniotomy Nursing Diagnosis
- Ineffective cerebral tissue perfusion related to cerebral edema
- Risk for imbalanced body temperature related to damage to the hypothalamus, dehydration, and infection
- Potential for impaired gas exchange related to hypoventilation, aspiration, and immobility
- Disturbed sensory perception related to periorbital edema, head dressing, endotracheal tube, and effects of ICP
- Body image disturbance related to change in appearance or physical disabilities
Epilepsy Nursing Diagnosis
- Risk for injury related to seizure activity
- Fear related to the possibility of seizures
- Ineffective individual coping related to stresses imposed by epilepsy
- Deficient knowledge related to epilepsy and its control
Brain Injury Nursing Diagnosis
- Ineffective airway clearance and impaired gas exchange related to brain injury
- Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and possible seizures
- Deficient fluid volume related to decreased LOC and hormonal dysfunction
- Imbalanced nutrition, less than body requirements, related to increased metabolic demands, fluid restriction, and inadequate intake
- Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage
- Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the brain
- Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness
- Disturbed thought processes (deficits in intellectual function, communication, memory, information processing) related to brain injury
- Disturbed sleep pattern related to brain injury and frequent neurologic checks
- Interrupted family processes related to unresponsiveness of patient, unpredictability of outcome, prolonged recovery period, and the patient’s residual physical disability and emotional deficit
- Deficient knowledge about brain injury, recovery, and the rehabilitation process
