ASSESSMENT NURSING BACKGROUN NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS D OBJECTIVES INTERVENTION

KNOWLEDGE
Subjective: Ineffective Temporary Short Term: Independent: GOAL MET
“Naawanan nak Cerebral blockage of large
latta met iti tissue or small cerebral After 4 hours of 1. Monitor 1. Fluctuation After 4 hours of
puoten ken han perfusion vessel nursing vital signs s in nursing
ko marikna related to intervention, the noting: pressure intervention, the
imimak ken insufficient patient will be able blood and changes patient was able to:
sakak. Nasakit blood flow as Atherothromboti to: pressure, in rate may  Demonstrat
py t barukong evidenced by c or embolic  Demonstrat heart rate occur e stable
ko” as verbalized chest pain, cause e stable and rhythm, because of vital signs
by the patient sudden loss vital signs and cerebral and
of and respiratory pressure or absence of
Objective: consciousnes Complete absence of rate injury in the signs of
s, numbness, resolution of signs of vasomotor increased
 Confusio fatigue symptoms within increased area of the ICP.
n few hours of ICP. brain that  Display no
 Trouble onset  Display no may cause further
speaking further brain deterioratio
 Fatigue deterioratio damage. n or
 Dizzines There may be n or recurrence
s mild tissue recurrence 2. Maintain 2. Absolute of deficits.
ischemia and of deficits. bedrest, rest and
hypoxia provide quiet may
responsible for quiet be needed
transitory environmen to prevent
symptomatology t, and recurrence
of patient restrict of bleeding
visitors or in the case
activities, of
Specific clinical as hemorrhagi
presentation of indicated. c stroke.
the patient .
correlates with
the area of brain 3. Administer
affected due to medications 3. Treatments
ischemia , as (including
indicated. medications
) depend on
the cause of
the stroke
(i.e.,
ischemic or
hemorrhagi
c) and
managemen
t of
associated
symptoms
and under
lying
conditions.
 DATE & TIME FOCUS PROGRESS NOTE
12-12-2022 Ineffective cerebral tissue perfusion related D: “Naawanan nak latta met iti puoten ken
to insufficient blood flow as evidenced by han ko marikna imimak ken sakak. Nasakit py
chest pain, sudden loss of consciousness, t barukong ko” as verbalized by the patient;
numbness and fatigue confusion; trouble speaking; fatigue; dizziness

A: Monitor vital signs noting: blood pressure,

heart rate and rhythm, and respiratory rate;
Maintain bedrest, provide quiet environment,
and restrict visitors or activities, as indicated;
Administer medications as indicated;
Trimetazidine; Phosphatidyl choline;
Isosorbide mononitrate; Clopidogrel;
Terbutaline

R: Pt demonstrated stable vital signs and

absence of signs of increased ICP; displayed
no further deterioration or recurrence of
deficits after 4 hours of nursing intervention

ASSESSMENT NURSING BACKGROUN NURSING NURSING RATIONALE EVALUATION

 DIAGNOSI D OBJECTIVES INTERVENTIO
S KNOWLEDGE N
Subjective: Impaired Temporary Short Term: Independent: GOAL MET
“Naawanan nak physical blockage of
latta met iti mobility large or small After 4 hours of 1. Monitor 1. Flaccid After 4 hours of
puoten ken han related to cerebral vessel nursing intervention, vital signs paralysis nursing intervention,
ko marikna decrease in the patient will be noting: may interfere the patient was able
imimak ken muscle able to: blood with to:
sakak. Nasakit control or Atherothromboti  Maintain or pressure, patient’s  Maintain or
py t barukong strength as c or embolic increase heart rate ability to increase
ko” as verbalized evidenced cause strength and support the strength and
and
by the patient by postural function of head, function of
rhythm,
instability, affected or whereas affected or
Objective: alteration in Complete and spastic
compensato compensato
gait resolution of ry body respirator paralysis
y rate ry body
 Confusio symptoms part. may lead to
within few hours deviation of part.
n  Maintain
of onset optimal 2. Maintain the head to  Maintain
 Trouble
position of neutral one side. optimal
speaking position of
function as position
 Fatigue of the function as
There may be evidenced 2. Aids in
 Dizzines mild tissue head. retraining evidenced
by the
s ischemia and absence of neuronal by the
hypoxia contractures pathways, absence of
responsible for and foot enhancing contractures
transitory drop. propriocepti and foot
symptomatology on and motor drop.
of patient response.

Specific clinical
presentation of
the patient 3. Assist
correlates with client to
the area of brain develop
affected due to upright
sitting
ischemia balance
(such as
raise
head of
bed a bit
higher
every day
for
several
days (e.g.,
from 45
to 60
degrees)