Nursing Care Plan

Cues and Clues Subjective Data : Reported left upper extremity weakness Objective Data : Slurring of speech *asa hx lng tohhh ehh.. Paedit nyo nlng sa kanila.

Nursing Diagnosis Ineffective Cerebral Tissue Perfusion Related to disruption of blood flow to the brain Secondary to??? Occlusion of blood vessel in the brain??? ?? :D

Rationale A clot into the cerebral circulation may cause a localized cerebral infarct which impedes the blood flow to the brain. As a result there is a decreased amount of oxygen supplied to the brain which is then may then cause tissue ischemia that may lead to inability to move one or more limbs on one side of the body and inability to formulate speech ,

Expected Outcome Short Term After 8 hours of nursing interventions patient will be able to: Maintain usual level of consciousness with a GCS of 15 Demonstrate stable vital signs with absence if signs of inc ICP Long Term After 3 days of nursing interventions patient will be able to Does not develop any complication of increase ICP, cerebral whatever.. bsta may mas-ok p. Burahin nyo nlng tong red. Ginawa ko lng black ang suggestion nyo

Interventions

Rationale

Evaluation Short Term After 8 hours of nursing interventions patient was able to: Maintain usual level of consciousness with a GCS of 15 Demonstrate stable vital signs with absence if signs of inc ICP Long Term After 3 days of nursing interventions patient was able to: Display no further recurrence of slurring of speech

Monitor/document neurologic status frequently and compare with baseline. Position with head slightly elevated and in neutral position. Maintain bedrest, provide quiet environment, restrict visitors/activities as indicated.

Assesses trends in level of consciousness.

Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation/perfusion. Continual stimulation/activity may increase ICP. Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage. Reduces hypoxemia

Administer supplemental o2 as indicated Administer medications as indicated

May help limit ischemic injury, reduce risk of recurrence of stroke, improve cerebral blood flow.