Community Nursing Care for a Patient with Ischemic Stroke: A Case Study.

Abstract

      This study aimed to the nursing care of a patient with ischemic stroke receiving continuous community-based care using the nursing process, home visits, and holistic assessment based on the INHOMESSS framework to promote functional recovery, prevent complications, reduce the risk of recurrent stroke, and enhance the capacity of the patient and family for long-term self-care. This case study involved an 81-year-old Thai woman diagnosed with ischemic stroke with underlying hypertension and lumbar spinal stenosis. Following stabilization during the acute phase, she received continuous community-based nursing care through four home visits conducted between May and July 2026. The nursing process, including assessment, nursing diagnosis, care planning, implementation, and evaluation, was systematically applied. Holistic assessment using the INHOMESSS framework covered mobility, nutritional status, home environment, caregiver support, medication management, safety, spiritual health, and access to health services. Nursing interventions included health education, medication adherence counseling, rehabilitation exercises, fall prevention, risk factor modification, and coordination with family members, a multidisciplinary healthcare team, and village health volunteers.

      Results: The patient consistently adhered to prescribed medications and treatment plans. Functional mobility gradually improved, enabling her to ambulate safely within the home using a walking cane and perform activities of daily living with greater independence. No falls, pressure injuries, joint contractures, mobility-related complications, or recurrent stroke were observed during follow-up. The caregiver and family demonstrated improved knowledge, confidence, and active participation in rehabilitation, medication management, home safety modification, and recognition of stroke warning signs, contributing to effective and continuous home care.