What is the primary nursing diagnosis for a long-term care patient with cerebral infarction resulting in right side dominant hemiparesis (weakness on one side of the body) and hemiplegia (paralysis on one side of the body)?

Primary Nursing Diagnoses for Long-Term Care Patient with Cerebral Infarction and Right-Sided Hemiparesis/Hemiplegia

The primary nursing diagnosis is Impaired Physical Mobility related to right-sided hemiparesis and hemiplegia, which directly drives the risk for multiple life-threatening complications including aspiration pneumonia, venous thromboembolism, pressure injuries, and falls. 1

Critical Priority Diagnoses

1. Impaired Physical Mobility

• This is the foundational diagnosis that cascades into nearly all other complications in stroke patients with hemiplegia 1
• Immobility accounts for up to 51% of deaths within the first 30 days after ischemic stroke 1
• Right-sided dominant weakness creates specific challenges with transfers, positioning, and activities of daily living 1
• The affected shoulder requires special positioning in maximum external rotation for 30 minutes daily to prevent subluxation 2
• Never pull on the affected arm during transfers or repositioning 1, 2

2. Risk for Aspiration

• Up to 78% of acute stroke patients experience dysphagia, with approximately 50% of aspirations being silent and unrecognized 1
• Dysphagia increases aspiration pneumonia risk 7-fold and is an independent predictor of mortality 1
• No oral feeding should be initiated before formal swallowing assessment using an evidence-based tool 1, 2
• This assessment must be performed even after initial recovery, as swallowing dysfunction can persist 1

3. Risk for Impaired Skin Integrity (Pressure Injury)

• Regular skin assessment using the Braden scale is mandatory 1
• Risk factors include older age, modified Rankin Scale score 3-5, higher NIHSS score, diabetes, incontinence, and longer length of stay 1
• Reposition at least every 2 hours to prevent pressure ulcers, with particular attention to the affected side 1, 2
• Use specialized mattresses and wheelchair cushions until mobility returns 1

4. Risk for Venous Thromboembolism

• Immobility after stroke dramatically increases DVT and pulmonary embolism risk 1
• Pulmonary embolism accounts for substantial post-stroke deaths, occurring between 3-120 days after initial stroke 1
• Apply intermittent pneumatic compression (IPC) devices within the first 24 hours for high-risk patients 2
• Early mobilization when hemodynamically stable is essential to reduce thromboembolism risk 1, 2

5. Impaired Urinary Elimination

• Urinary incontinence occurs in 30-60% of patients in early recovery and is the major factor in nursing home placement 1
• Indwelling catheters should not be used for more than 48 hours due to UTI risk 2
• Implement bladder training with scheduled toileting every 2 hours during waking hours and every 4 hours at night 1, 2
• Perform intermittent catheterization every 4-6 hours if postvoid residual volume exceeds 100 mL 1

6. Constipation

• Constipation contributes to decreased quality of life, limitation of social activities, and adverse outcomes including disability and poor neurological function 1
• Early occurrence (day 2 of admission) calls for prompt preventive interventions 1
• Implement bowel training program integrating stool softeners, laxatives, and enemas as needed 1
• High fluid intake during the day should be encouraged 1

7. Risk for Injury (Falls)

• Falls are a major complication of impaired mobility in stroke patients 1
• Perform fall risk assessment using validated tools to identify high-risk patients 2
• Consider bed/chair alarms and video monitoring 1
• Ensure clutter-free environment and properly fitted non-skid footwear 2
• Assist with all transfers and toileting 1

Secondary Priority Diagnoses

8. Risk for Ineffective Cerebral Tissue Perfusion

• Monitor for neurological deterioration, hemorrhagic transformation, cerebral edema, and recurrent stroke 1
• Cardiac complications account for 2-6% of mortality within first 3 months, with highest risk in first 2 weeks 1
• Continuous cardiac monitoring for at least 24 hours is needed 1

9. Imbalanced Nutrition: Less Than Body Requirements

• 50% of severe stroke survivors are malnourished at 2-3 weeks post-stroke 1
• Weight loss exceeding 3 kg indicates need for close nutritional monitoring 1
• Monitor intake/output, body mass index, caloric counts, serum protein, electrolytes, and blood counts 1

10. Risk for Ineffective Coping/Depression

• Depression is common after stroke, affecting up to one-third of patients and significantly impacting recovery 1, 2
• Clues can be subtle, such as declining to participate in therapy 1
• Screen all stroke patients for depression as it affects rehabilitation outcomes and quality of life 2
• Poststroke fatigue affects at least half of survivors and negatively impacts daily activities and rehabilitation participation 1

11. Impaired Verbal Communication (if applicable)

• Patients with aphasia may go undiagnosed or receive inadequate treatment for depression and other complications 1
• Refer to speech-language pathologist for formal assessment 1

Common Pitfalls to Avoid

• Never assume flat affect or aprosodic speech represents indifference—consider pseudobulbar affect as the underlying cause 3
• Do not misinterpret pseudobulbar affect (involuntary emotional displays) as depression—these are distinct conditions requiring different management 3
• Avoid pulling on the affected shoulder during any care activities, as subluxation is common and painful 1, 2
• Do not delay formal rehabilitation assessment—early rehabilitation is associated with improved outcomes 2
• Implement short, frequent mobilization sessions rather than infrequent, long sessions 1, 2