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Nursing Priority No. 1: Ineffective Cerebral Tissue Perfusion Related To Interruption of Blood Flow As Manifested by Changes in
Nursing Priority No. 1: Ineffective Cerebral Tissue Perfusion Related To Interruption of Blood Flow As Manifested by Changes in
Nursing Priority No. 1: Ineffective Cerebral Tissue Perfusion Related To Interruption of Blood Flow As Manifested by Changes in
NURSING
DIAGNOSIS
INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
hindi nya
magalaw yang
kaliwang kamay
at paa nya ng
kusa as
verbalized by
the wife
Objective:
> Slurring of
speech
> Weakness on
left arm and leg
> difficulty in
swallowing
Ineffective
cerebral tissue
perfusion
related to
interruption of
blood flow as
manifested by
changes in
motor
responses
Increase LDL
levels
Accelerated
atherosclerosis
Decreased
Tissue
perfusion in
brain
interruption of
blood flow in
brain
Ineffective
cerebral tissue
Perfusion
After 4 days of
nursing
intervention the
client will have
an effective
cerebral tissue
perfusion as
manifested by:
> display no
furher
deterioration of
deficits
>vital signs
within clients
normal range
>Establish rapport
>Monitor vital
signs
> Monitored intake
and output
> Position with
head slightly
elevated and in
neutral position
> Clustered and
organized activities
of the client
>To gain trust and
cooperation
>To obtain baseline
data
> to prevent volume
overload and deficit
> Reduces arterial
pressure by
promoting venous
drainage and may
improve cerebral
circulation/perfusion.
> to reduce
uneccesarry
movement and
GOAL MET.
After 4 days of
effective nursing
intervention the
client is able to
Maintain usual
level of
consciousness,
motor function
and vital signs
within normal
range
II. NURSING CARE PLAN
Nursing Priority No. 1: Ineffective cerebral tissue perfusion related to interruption of blood flow as manifested by changes in
motor responses
Cerebral
Hypoxia
Cerebral
ischemia
loss of cerebral
connections for
afferent
sensory and
efferent motor
nerves
changes in
motor
responses
inability to
purposely
move involved
body parts
> Encourage
rest.
> Instructed client
and family
members in ways
to minimize risk
factors for altered
tissue perfusion
>administer
medications as
ordered.
stimulation
> Rest prevents
tissue oxygen
demand and
enhances tissue
oxygen perfusion.
> Increases the
probability that
healthy adaptation
will continue