ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

OBJECTIVES

NURSING INTERVENTON Independent: Obtain initial vital signs and monitor hourly.

RATIONALE

EVALUATION

SUBJECTIVE: Nahihilo ako. As verbalized by the patient. OBJECTIVEs: Restlessness Dizziness Headache Slurred speech Fatigue Left side body weakness BP: 150/100 mm Hg

Altered cerebral tissue perfusion related to elevated blood pressure secondary to CVA, bleeding as manifested by headache, dizziness, slurred speech and restlessness.

Elevated Blood pressure

After 8 hrs. of nursing intervention the patient will: Have a BP within normal range of 120/80 mm Hg from the baseline BP which is 150/100 mm Hg. Demonstrate increase cerebral perfusion as evidenced by reduced headache and dizziness.

Increase pressure in small arteries in the brain Rupture of small arteries

Serve as baseline data and to evaluate progress of nursing care. To provide immediate care.

Goal Met. After 8 hrs. of nursing intervention the patient was able to : Have a BP within normal range of 120/80 mm Hg from the baseline BP which is 150/100 mm Hg. Demonstrate increase cerebral perfusion as evidenced by: - reduced headache and dizziness.

Monitor changes in mentation, vital signs,and signs of electrolyte imbalance.

Mass of blood is formed

Adjacent brain tissue is displaced and compressed Ischemia

Assess visual personality sensory or motor changes such as headache, dizziness and altered mental status. Elevate head of bed to 10 degrees.

To provide appropriat e care and evaluate the degree of altered cerebral perfusion. To promote circulation or venous drainage. To

Damage to right brain

Encourage adequate bed rest

hemisphere Altered cerebral perfusion Encourage patient to develop and use relaxation techniques Teach the patient about proper diet for HPN

decrease metabolic demands To decrease tension level. To promote awareness about proper diet and promote wellness as well . To aid in lowering the blood pressure of the patient.

Dependent: Administer antihypertensive drugs as ordered by the physician.