Assessment Nursing diagnosis Scientific explanation

Planning Intervention Scientific rationale Evaluation

February 23, 201001:30am

Subjective:

Stated:

“na stroke siya” stated by the client’s cousin

Objectives:

Speech abnormality

Behavioral changes: restlessness

Changes in motor response; extremity weakness: paralysis

Muscle strength of 1/5

Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to hemorrhage as evidenced by GCS of 7

⬆ intake of NaCigarette smoking

Imbalanced nutrition

vasoconstriction

⬆ intravascular pressure

⬆resistance to flow

Scarring of vessel

Thrombus formation

Emboli formation

Blocks the vessel in the brain

CVA

Reference: medical surgical nursing: 11th

edition volume 1 Brunner and Suddarath

Discharge outcome:

After 2 weeks of nursing intervention the client will be able to:Demonstrate

behaviors/lifestyle changes, therapy regimen to improve circulation example: cessation of smoking, relaxation techniques, exercise/dietary program.

Demonstrate increased perfusion as individually appropriate Example: skin warm/dry, peripheral pulses present/strong, pulses present/strong, vital signs within normal range,

independent:

Note customary baseline data

Review result of diagnostic study

Note history of syncope, brief/intermittent periods of confusion

Instruct in blood pressure monitoring at home, advice purchase of home monitoring equipment refer to community resources as indicated

Elevate HOB example: 10 degrees and maintain head

Provide comparison with current findings

To determine location/severity of condition

Suggestive of transient ischemic attack

Facilitate management of hypertension, which is a major risk factor for damage blood vessels/organ function

To promote circulation/ venous drainage

February 24, 2010 12:00pm

Discharge outcome:

Partially achieve

After 2 weeks of nursing intervention the client can be able to:

Demonstrate behaviors/lifestyle changes, therapy regimen to improve circulation example: cessation of smoking, relaxation techniques, exercise/dietary program.

Short term outcome:

Achieve

GCS of 7alert/oriented, balanced intake/output, absence of edema, free of pain/discomfort.

Short term out come:

After 2 days of nursing intervention the client will be able to: Verbalize

understanding of condition therapy regimen, side effects of medication and when to contact health care provider.

/neck in midline or neutral position

Administer medication such as catapress

Assist with monitor hypothermia therapy

Recommend with physical rehabilitation therapy

To promote pharmacologic regimen

Which may be used to decreases metabolic and O2 needs.

To have contact with other health care provider

After 2 days of nursing intervention the client cannot be able to:

Verbalize understanding of condition therapy regimen, side effects of medication and when to contact health care provider