CARAGAN, Chantal

STROKE
Assessment Diagnosis Goal Interventions Rationale and Outomes Evaluation
Subjective: Ineffective Short Term: Independent: Short Term:
“While we were Tissue After 24 hours 1. Monitor Vital Signs. 1. Increased ICP may After 24 hours
eating with him we Perfusion r/t of nursing 2. Monitor patient’s occur because of of nursing
just suddenly noticed inadequate interventions ICP and neurologic tissue clot interventions
that his speech was blood flow to patient will responses to care formation. patient was
slurring, the left side the brain from demonstrate activities. Elevated BP is able to
of his face started to the Right signs of 3. Monitor respiratory common demonstrate
droop and the left side Internal improved status to assess immediately after signs of
of his body was Carotid Artery cerebral changes in a stroke and may improved
getting weak.” As Origin through perfusion neurologic status. be a protective cerebral
verbalized by patient’s the Right 4. Avoid neck flexion or response to perfusion
colleague. Middle Long Term: extreme hip/knee maintain cerebral
Cerebral After 72 hours flexion. perfusion. Long Term:
Objective: Artery Trunk of nursing 5. Position with head Immediately After 72 hours
 BP – 145/90 as manifested intervention slightly elevated and following of nursing
 PR: 84 bpm by left facial patient, family, in neutral position. ischemic stroke, intervention
 Patient is droop, slurred caregiver (if 6. Fluid and electrolyte use of drugs to patient, family,
confused. speech, left they have) will balance must be lower BP is caregiver (if

 Left Facial motor be able to controlled carefully. recommended they have) was
Droop maintain The goal generally is only if BP is able to
CARAGAN, Chantal
STROKE
 Slurred speech effective to keep the patient markedly maintain
 Left Motor personal family adequately increased. effective
Weakness, coping and hydrated. 2. ICP can increase personal family
Lower limb 2/5 avoid 7. Assist with medical with changes in coping and
 Decreased complications procedures such as positioning and avoid
tone of stroke. Endovascular movement. About complications
 Altered Thrombectomy. 25% of patients of stroke.
sensation will worsen in the

 Mild Left Sided Dependent: first 24 to 48

Neglect 8. Administer IV tissue hours.

 Cerebral plasminogen 3. Acute care begins

Angiography: activator (tPA) as with managing

post MRI prescribed by the the airway,

demonstrated physician. breathing, and

Occlusive 9. Administer circulation.

Thrombus Metropolol Irregularities can

extending from (Lopressor) or suggest increase

the Right Nicardipine in ICP.

Internal (Cardene) as 4. To avoid

Carotid Artery prescribed by the obstruction of

Origin through physician. arterial and

CARAGAN, Chantal
STROKE
the Right venous blood
Middle flow.
Cerebral Artery Collaborative: 5. Reduces arterial
Trunk. 10. Collaborate with a pressure by
 Endovascular physiatrist. promoting venous
Thrombectom drainage and may
y improve cerebral
perfusion.
6. To promote
perfusion and
decrease further
brain injury.
Check I & O every
2 hours for the
first 24 hours.
7. Endovascular
Thrombectomy is
to improve
peripheral
circulation.
8. To reestablish
CARAGAN, Chantal
STROKE
blood flow
through a blocked
artery to prevent
cell death in
patients with the
acute onset of
ischemic stroke
symptoms.
9. Use of drugs to
lower BP is
recommended
only if BP is
markedly
increased (mean
arterial pressure
greater than 130
mmHg)
10. A physician who
specializes in
physical medicine
and
CARAGAN, Chantal
STROKE
rehabilitation.

1st Nursing Diagnosis: Ineffective Tissue Perfusion r/t inadequate blood flow to the brain from the Right Internal Carotid Artery
Origin through the Right Middle Cerebral Artery Trunk as manifested by left facial droop, slurred speech, left motor
2nd Nursing Diagnosis: Impaired physical mobility r/t decreased cerebral blood flow as manifested by Hemiparesis (Left side)
3rd Nursing Diagnosis: Impaired Verbal Communication r/t decreased cerebral blood flow as manifested by slurred speech