ASSESSMENT

DIAGNOSIS

Subjective:
Patient verbalized
nahihilo at
naghihina ako.

Ineffective
cerebral
tissue
perfusion r/t
interruption
of blood flow

Objective:
Ct scan results:
chronic small vessel
ischemic changes
(+) History of high
blood pressure
(+) weakness in both
upper and lower
extremities

PLANNING
After 4 hours of
nursing
intervention, patient
will be able to
display decrease
signs of ineffective
tissue perfusion as
evidence by gradual
improvement of
vital signs.

INTERVENTION

RATIONALE

1. Establish rapport.

1. To promote
cooperation.

2. Monitor vital signs.

2. To have a base line

data, assess
changes in
neurologic status.

3. Check capillary refill

and conjunctiva for
paleness.

3. To determine blood
circulation.

4. Elevate head of bed to

30 degrees as ordered

4. To promote
circulation.

5. Maintain bedrest,
provide quiet and
relaxing environment,
and restrict visitors and
activities.

5. Enough rest is
needed to
conserve energy.

6. Cluster nursing
interventions and
provide rest periods
between care activities.
Limit duration of
procedures.
7. Avoid neck flexion and
extreme hip/knee
extension.

6. Continuous
stimulation or
activity can
increase
intracranial
pressure (ICP).
7. To avoid
obstruction

EVALUATION

of arterial and
venous blood flow.
8. Provide and maintain
oxygen as ordered.
9. Perform GCS monitoring
as ordered.

10.Evaluate pupils, noting

size, shape, equality,
light reactivity

11.Administer medications
as ordered.

8. Aids in difficulty
of breathing.
9. To detect changes
indicative
of worsening or
improving
condition.
10.To determine
whether the brain
stem is intact. Pupil
size and equality is
determined by
balance between
parasympathetic
and sympathetic
innervation.
11.To promote
wellness

ASSESSMENT
Subjective:
Patient verbalized
nahihilo at
naghihina ako.
Objective:
Ct scan results:
chronic small vessel
ischemic changes
(+) History of high
blood pressure
(+) weakness in both
upper and lower
extremities

DIAGNOSIS
Risk for injury r/t
generalized
weakness secondary
to CVA.

PLANNING
Long Term
After 3 days of NI,
patient will remain
free from injury AEB
absence
of abrasion/falls.

INTERVENTION

RATIONALE

1. Establish rapport.

1. To promote
cooperation.

2. Monitor vital
signs.

2. To have a
baseline data.

3. Keep the side

rails of the bed
raised.
4. Remind client to
walk slowly, and
to have rest
between
intervals of
walking.
5. assist patient
with activities

3. To protect from
falling out of bed.
4. To prevent injury.

5. for continuous
monitoring and
guidance to the
client
to protect from
injury

EVALUATION