ASSESSMENT NURSING PLANNING NURSING EVALUATION

INTERVENTION/
DIAGNOSIS RATIONALE
SUBJECTIVE Ineffective cerebral SHORT TERM -Assess neurological -The improvement
tissue Perfusion Within 8 hour of status of the patient. of one’s condition
“Hirap siyang related to nursing from worse to good
>Glasgow coma scale
gisingin at interruption of intervention patient should be greater than status with
makausap ng blood flow. will not: manifest 8 score. conscious and
maayos” as or display any >Level of slightly mobility
verbalized by signs of further consciousness is starting to reoccur.
patient’s son. deterioration or either awake or can be
readily awakened from
recurrence of -Display no further
normal sleep.
OBJECTIVE deficits. deterioration/
recurrence of
-LOC: Stupurous LONG TERM deficits
with left side 3 days monitor the
paralysis. patient to >Use of pulse
oximeter to closely
-GCS: 7/15 participate factor
monitor the current
-Not responding in related to situation of the patient
conversation individual situation >Give oxygen by using
-Difficulty in stay for decreases nasal canula
awake/waking up cerebral perfusion
and potential for
BP: 180/100 increased
O2SAT: 93-94% intracranial
RR: 12 (Respiration pressure.
Rate)
Pulse Rate: 95
Age: 61years old
 ASSESSMENT NURSING PLANNING Nursing EVALUATION
Intervention/
DIAGNOSIS RATIONALE
SUBJECTIVE Impaired SHORT TERM =Assess >Maintain/
physical mobility muscular Increase the
“Nanghihina ang related to Change strength strength and
katawansabawatarawnalumipas” neuromuscular positions at function of
as verbalized by the patients involvement. least in every 2 >Place the affected or
son” hour (Supine, important things compensatory
Side lying) and the patient body port.
OBJECTIVE possibly more easily to reach
often if placed > Side rails up >Maintain optimal
>Impaired ability to moved lower on affected position of
extremities side. function as
>LOC: Stupurous with left side evidenced by
>Lovett scale LONG TERM absence of
RU:3/5 >Referral to contractures foot
RL:3/5 Set goals within rehabillitation to drop.
LU:0/5 3 day to patient improve one's
LL:0/5 for participation strength >Demonstrate
in activities and >Time for techniques/
BP: 180/100 position excercise and behaviors that
O2SAT: 93-94% changes. rest. can enable
RR: 12 (Respiration Rate) resumption of
Pulse rate: 95 activities
Age: 61years old
>Maintain skin
integrity
 local Acidosis

Anaerobic Aphasia
Aerobic
Respiration
Respiratopn

SIGN AND
BRAIN SYMPTOMS
TISSUE
NECROSIS -Hemiplegia

-Hemiparesis

DEATH -Dysarthria

-Arphasia

-Dysphasia

-Flaccid paralysis