I.

Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Objective: Impaired tissue After 8 hrs of nursing 1. Establish rapport. 1. To promote cooperation Patient shall display a decrease
perfusion r/t intervention the pt will 2. Monitor vital signs. 2. To have baseline data, assess signs of tissue perfusion gradual
(+) dizziness
interruption of blood be able to display changes in neurologic status improvement of vital signs.
(+) restlessness flow secondary to decrease signs of 3. Check capillary refill and 3. To determine blood circulation
BP: 130/90 mmHg
hemorrhagic stroke ineffective tissue conjunctiva for paleness.
(+) difficulty moving limbs perfusion as evidence 4. Position with head slightly 4. Reduces arterial pressure by RR: 18 bpm
BP: 180/110 mmHg by gradual elevated and in neutral promoting venous drainage and
improvement of vital positions. may improve cerebral GCS: 8
RR: 23 signs and neurologic circulation and perfusions.
status. 5. Advise patient to have enough
PR: 81
rest. 5. Enough rest is needed to
conserve energy
6. Avoid neck flexion and extreme
hip/knee extension.
6. To avoid obstruction of arterial
7. Provide and maintain oxygen as and venous blood flow.
ordered 7. Aids in difficulty of breathing

8. Perform GCS monitoring as

ordered. 8. To detect changes indicative of
worsening or improving
9. Administer medication as condition
ordered. 9. To promote wellness.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION