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DATE/TIME CUES E NURSING DIAGNOSIS OBJECTIVES OF CARE NURSING INTERVENTIONS EVALUATION

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D

August 26, 2021 A Ineffective cerebral tissue Short term: 1. Document neurological status August 26, 2021
Objective: C perfusion related to interruption frequently and compare with @ 11:00 am
7am to 3pm shift
- In due to T of blood flow as evidenced by After 3 hours of nursing baseline. Perform GCS monitoring
@ 8 am decreased in I decreased in sensorium, interventions, the patient will: as ordered. Short term:
sensorium. V confusion, secondary to CVA. R: Assessing level of “GOAL MET!”
- pt. is anxious I 1. Verbalize consciousness and
- agitated T understanding of the potential for increased ICP After 3 hours of nursing
- Confused during Y situation and risk and is useful in interventions, the patient
verbal response - factors, individual determining location, was able to:
- GCS: 13 E therapeutic regimen, extent, and progression of
- CCT-Scan: CVA X and safety measures CNS damage. Also, to 1. Verbalized
Infarction E Rationale: A cerebrovascular to improve circulation detect changes indicative understanding of
R accident (CVA), is a sudden loss of such as cessation of of worsening or improving the situation and
VS: C brain function resulting from a smoking, relaxation condition. risk factors,
BP: 180/100 I disruption of the blood supply to techniques, individual
mmHg S a part of the brain. (Brunner & exercise/dietary 2. Assess vital signs. Take note of therapeutic
PR: 65 bpm E Suddarth, 2010) program. Change- find hypertension and hypotension. regimen, and
more appropriate and R: Fluctuations in pressure safety measures to
P The presence of partial blockage short term. may occur because of improve circulation
A of the blood vessel can be cerebral pressure in the such as cessation
T multifactorial. These can be due vasomotor area of the of smoking,
T to vasoconstriction, fat brain. relaxation
E accumulation and therefore techniques,
R decreases elasticity of vessel wall 3. Monitor the pt. for any signs and exercise/dietary
N leading to alteration of blood Long term: symptoms of potential increase in program.
perfusion with the initial clotting ICP such as decreased alertness,
consequence. This may later lead After 2 days of nursing sudden headache. Long term:
to the development of thrombus interventions, the R: To facilitate early “GOALS PARTIALLY MET!”
which can be loosened and client will be able to detection and
dislodged in some areas of the demonstrate management. As increased After 2 days of
brain that may lead to alteration increased perfusions ICP can be life-threatening nursing
of blood perfusion and further as individually as it may lead to further interventions, the
develop to cerebral infarct. (Vera, appropriately as brain damage. client was able to
M., 2013) evidenced by: demonstrate
- Warm skim 4. Auscultate pt. for murmurs. increased
- vital signs on normal Monitor heart rate and rhythm. perfusions as
range, R: Change in rate, individually
- alert and oriented. especially bradycardia, can appropriately.
- Free of discomfort. occur because of increased - Warm skim
cerebral pressure. - vital signs: BP:
Dysrhythmias and 120/100 mmHg
murmurs may reflect - alert and oriented.
cardiac disease, which - Free of discomfort
have precipitated CVA. (not met)

5. Administer clopidogrel 75 mg AC as
ordered.
R: Clopidogrel is an
antiplatelet drug which
prevents blood clotting
that may cause heart
attack or stroke as
preexisting hypertension,
or cardiovascular disease
requires cautious
treatment because
aggressive management
increases the risk of
extension of tissue
damage.

6. Elevate the head of the bed at 30

 degrees and maintain head or neck
in midline.
R: To promote circulation
or venous drainage from
the patient’s head to the
rest of the body to
decrease ICP.

7. Observe and record pallor, pulse

deficits, temperature of skin, and
distention of skin.
R: Symptomatology is
dependent on degrees of
ischemia or obstruction
present.

8. Provide restful, quiet environment.

R: To minimize stress that
stimulates vasoconstrictor.

9. Provide information regarding the

client’s condition.
R: To increase the client
and family’s knowledge
about the condition.

10. Discuss with patient’s family the

ways in which they can assist
client’s self-care needs.
R: Varying levels of
assistance may be required
to be planned for bases on
individual situation.