Assessment Nursing diagnosis Scientific Planning Intervention Scientific rationale Evaluation

explanation
February 23, 2010 Discharge outcome: independent: February 24, 2010
01:30am ⬆ intake of Na 12:00pm
Ineffective cerebral Cigarette smoking After 2 weeks of  Note customary  Provide
Subjective: tissue perfusion Imbalanced nutrition nursing intervention baseline data comparison with Discharge outcome:
related to interruption the client will be able current findings
Stated: of blood flow vasoconstriction to: Partially achieve
secondary to  Demonstrate  Review result of  To determine
“na stroke siya” hemorrhage as behaviors/lifestyle diagnostic study location/severity of After 2 weeks of
stated by the client’s evidenced by GCS of ⬆ intravascular changes, therapy condition nursing intervention
cousin 7 pressure regimen to the client can be able
improve to:
⬆resistance to flow circulation  Suggestive of
Objectives: example:  Note history of transient ischemic  Demonstrate
Scarring of vessel cessation of syncope, attack behaviors/lifestyle
smoking, brief/intermittent changes, therapy
 Speech Thrombus formation relaxation periods of regimen to
abnormality techniques, confusion improve
Emboli formation exercise/dietary circulation
 Behavioral program.  Instruct in blood  Facilitate example:
changes: Blocks the vessel in pressure management of cessation of
restlessness the brain  Demonstrate monitoring at hypertension, smoking,
increased home, advice which is a major relaxation
CVA perfusion as purchase of home risk factor for techniques,
 Changes in individually monitoring damage blood exercise/dietary
motor appropriate equipment refer to vessels/organ program.
response; Example: skin community function
Reference: medical
extremity warm/dry, resources as
surgical nursing: 11th peripheral pulses indicated Short term outcome:
weakness:
paralysis edition volume 1 present/strong,
Brunner and pulses  To promote
 Muscle Suddarath present/strong,  Elevate HOB circulation/ venous Achieve
strength of 1/5 vital signs within example: 10 drainage
degrees and
 normal range, maintain head After 2 days of
alert/oriented, /neck in midline or nursing intervention
 GCS of 7 balanced neutral position the client cannot be
intake/output, able to:
absence of  To promote
edema, free of  Administer pharmacologic
pain/discomfort. medication such regimen  Verbalize
as catapress understanding of
 Which may be condition therapy
used to decreases regimen, side
Short term out come:  Assist with monitor metabolic and O2 effects of
hypothermia needs. medication and
After 2 days of therapy when to contact
nursing intervention health care
the client will be able  To have contact provider
to: with other health
 Verbalize  Recommend with care provider
understanding of physical
condition therapy rehabilitation
regimen, side therapy
effects of
medication and
when to contact
health care
provider.