Conditions › Neurological
Stroke Nursing Care Plan and Interventions
Stroke nursing care starts with BE FAST recognition, a noncontrast head CT and the time last known well, because alteplase and thrombectomy are time limited. Keep the client NPO until a dysphagia screen, control BP to the ordered target and watch neuro checks closely after treatment.
Stroke nursing care plan
| Nursing problem | Goal | Key interventions |
|---|---|---|
| Ineffective cerebral tissue perfusion | Neuro checks stable or improving; BP inside the ordered range. | |
| Risk for aspiration | Nothing by mouth until a swallow screen is passed; no aspiration. | |
| Risk for bleeding (after alteplase) | No new headache, neuro decline or bleeding during and after the infusion. | |
| Impaired mobility and self-care deficit | No falls or pressure injury; works toward rehab goals. |
Problem wording is plain-language nursing diagnosis style. Your program may require NANDA-I labels and your own assessment data.
What it is
Stroke (CVA)
Part of the brain loses its blood flow, from a blocked artery or a burst one. Brain cells begin to die within minutes. 1
Time is brain: every minute of delay costs function.
Ischemic stroke
A clot blocks a brain artery: plaque from atherosclerosis, or an embolus that travels in. About 87% of strokes. 2
AFib is the classic embolus source: a clot forms in the left atrium and flies to the brain.
Hemorrhagic stroke
A vessel ruptures. In the brain, usually from hypertension; around it (subarachnoid), a ruptured aneurysm. Pressure in the skull rises. 3,1
Clues of a bleed: worst headache of their life, vomiting, falling level of consciousness.
Assessment: what you will see
BE FAST
Balance, Eyes (vision loss or double vision), Face droop, Arm drift, Speech slurred or jumbled, Time to call for help. 1
Ask when they were last known well (last seen normal). That time starts the treatment clock.
Head CT without contrast
The first scan in any suspected stroke. It shows whether there is a bleed, which decides the treatment. 2
No clot buster until CT rules out a bleed: it would make the bleeding worse.
Left hemisphere stroke
Right-sided weakness and aphasia, because the left side of the brain usually runs language. 4,5
Use short, simple sentences, yes-or-no questions, gestures or pictures, and give extra time.
Right hemisphere stroke
Left-sided weakness and left neglect: they ignore the left side of the body and room and may deny the weakness. 4
Unaware of deficits, so high fall risk. Cue them to turn the head and scan to the left.
Complications and red flags
Stroke complications
Brain: swelling, bleeding into the stroke, seizures. Body: aspiration, falls, pressure injury, VTE. 2
Drowsier or a new deficit on the neuro check? Report it right away.
Priority: what the nurse does first
Suspected stroke: first actions
Activate the stroke team. Airway and alignment, vital signs, fingerstick glucose, 2 IV lines, accurate weight, STAT CT. 2
Check glucose early: hypoglycemia can mimic a stroke.
Dysphagia screen
NPO, including pills, until a trained nurse or speech-language pathologist does a swallow screen. 2,4
Client asks for a sip of water before the screen? Hold it. Aspiration is a preventable complication.
Nursing interventions and treatment
Alteplase in ischemic stroke
IV thrombolytic that dissolves the clot. Ischemic only, after CT rules out a bleed, within 3 to 4.5 hours of last known well. 2,4,6
Tenecteplase (FDA-approved 2025) is an alternative. Main risk of both: bleeding, especially in the brain.
Before alteplase: screen
BP must be below 185/110. Hold for active bleeding, stroke or head trauma in 3 months, low platelets or anticoagulation. 4
AFib alone is not a reason to withhold alteplase. Exclusions are about bleeding risk.
Mechanical thrombectomy
A catheter, usually through the groin, pulls the clot out of a large brain artery. Possible up to 24 hours in selected clients. 2
It can follow alteplase. Afterward, check the access site and the pulses below it.
Permissive hypertension
After ischemic stroke, the brain around the dead core needs pressure. Without alteplase, BP may run up to 220/120. 2
Don't rush to lower BP in an ischemic stroke. In a bleed, high BP is the enemy.
Hemorrhagic stroke care
No thrombolytics, antiplatelets or anticoagulants. Reverse warfarin (IV vitamin K plus clotting factors). Lower SBP 150 to 220 toward 140. 4,3
Raise the head of the bed for ICP and watch for seizures.
Evaluation: is care working?
After alteplase
Neuro checks and vital signs often. BP below 180/105 for 24 hours. No antiplatelets or anticoagulants for 24 hours; avoid IM shots. 4,6
Sudden headache, vomiting or a worse neuro check: stop the infusion per protocol and call now.
Client teaching
Stroke prevention teaching
After ischemic stroke: daily antiplatelet and statin (anticoagulant if AFib). Control BP, cholesterol, diabetes. Quit smoking, stay active. 2,4
Any BE FAST sign, even one that fades: call 911 and note the time.
NCLEX traps
Stroke vs TIA
Both start with the same sudden deficits. A TIA fully resolves, usually within an hour, with no infarct on imaging. A stroke leaves damage. 2,4
You can't tell them apart at onset: treat every new deficit as a stroke and note the time.
Try 2 stroke questions
NCLEX-style, approved by a licensed RN. Pick an answer, check it, then read the rationale.
Question 1 · Management of Care
A client presents to the emergency department with facial drooping, left arm weakness, and slurred speech that began 45 minutes ago. Using the FAST assessment, what is the nurse's priority action?
Show answer and rationale
Answer: B. FAST stands for Face drooping, Arm weakness, Speech difficulty, and Time to call for help, and rapid recognition with immediate notification of the stroke team is critical because tPA has a narrow treatment window for ischemic stroke. Scheduling a future appointment or simply observing wastes critical time when brain tissue is at risk. Aspirin should not be given until hemorrhagic stroke is ruled out by CT scan, since it could worsen a bleed. Time is brain, so acting immediately and documenting exact onset time is the priority.
Checked against: OpenStax Medical-Surgical Nursing, 15.1; OpenStax Medical-Surgical Nursing, 15.2
Question 2 · Physiological Adaptation
A client arrives at the emergency department with signs of acute ischemic stroke. The client was last known well 2 hours ago. Which action should the nurse anticipate first?
Show answer and rationale
Answer: D. A noncontrast CT scan of the head comes first because it rules out hemorrhagic stroke, and giving tPA to a client who is bleeding into the brain could cause a fatal hemorrhage. tPA is considered only after imaging excludes bleeding and only within 4.5 hours of the time the client was last known well, so giving it immediately skips a required safety step. Lowering the blood pressure does not delay the CT, but in a client who is a tPA candidate the BP must be brought below 185/110 mm Hg before tPA is started and then kept below 180/105 mm Hg for at least 24 hours afterward. Waiting until the 4.5 hour window closes would make the client ineligible for this time-sensitive treatment.
Checked against: OpenStax Medical-Surgical Nursing, 15.1; OpenStax Medical-Surgical Nursing, 15.2
Keep studying stroke in NurseLingo Pro
Pro has 55 stroke questions like these, with a rationale for every answer. Everything for stroke in one place. A free account gets 5 free opens of any condition; Pro opens all 277.
Test yourself: free med-surg practice questions with answers and rationales.
Frequently asked questions
What are the priority nursing diagnoses for stroke?
Common nursing problems for stroke include ineffective cerebral tissue perfusion; risk for aspiration; risk for bleeding (after alteplase); impaired mobility and self-care deficit. Choose the ones your assessment supports and rank airway, breathing and circulation problems first.
What does the nurse do first for stroke?
Activate the stroke team. Airway and alignment, vital signs, fingerstick glucose, 2 IV lines, accurate weight, STAT CT. NPO, including pills, until a trained nurse or speech-language pathologist does a swallow screen.
More neurological
Related cheat sheets
Sources
- OpenStax Medical-Surgical Nursing, 15.1
- OpenStax Medical-Surgical Nursing, 15.2
- OpenStax Medical-Surgical Nursing, 15.3
- merckmanuals.com
- nidcd.nih.gov
- dailymed.nlm.nih.gov
For study only, not medical advice. Follow your program, your facility's policies and the provider's orders.