1. The patient presented with an altered level of consciousness possibly due to coagulopathy from a stroke.
2. Over the next 24 hours, the nursing care plan aims to maintain or improve the patient's level of consciousness, cognition, motor function and vital signs while monitoring for increased intracranial pressure.
3. Interventions include frequent assessments of vital signs, neurological function, factors contributing to decreased cerebral perfusion and signs of neurological deterioration which could require transferring the patient to critical care.
1. The patient presented with an altered level of consciousness possibly due to coagulopathy from a stroke.
2. Over the next 24 hours, the nursing care plan aims to maintain or improve the patient's level of consciousness, cognition, motor function and vital signs while monitoring for increased intracranial pressure.
3. Interventions include frequent assessments of vital signs, neurological function, factors contributing to decreased cerebral perfusion and signs of neurological deterioration which could require transferring the patient to critical care.
1. The patient presented with an altered level of consciousness possibly due to coagulopathy from a stroke.
2. Over the next 24 hours, the nursing care plan aims to maintain or improve the patient's level of consciousness, cognition, motor function and vital signs while monitoring for increased intracranial pressure.
3. Interventions include frequent assessments of vital signs, neurological function, factors contributing to decreased cerebral perfusion and signs of neurological deterioration which could require transferring the patient to critical care.
OBJECTIVE: Ineffective Cerebral After 24 hours, the patient 1. Assess factors 1. Assessment will determine After 24 hours, the patient Loss of Perfusion maybe r/t will maintain; related to individual and influence the choice of will maintain; consciousness coagulopathy as 1. Maintain usual situation for interventions. Deterioration in 1. Maintain usual VS taken: evidenced by altered or improved decreased cerebral neurological signs or failure to or improved BT: 36 LOC. LOC, cognition, perfusion and improve after initial insult LOC, cognition, BP: 180/120 and motor and potential for may reflect decreased and motor and PR: 78 sensory function. increased ICP. intracranial adaptive capacity sensory function. RR: 18 2. Demonstrate 2. Changes in blood requiring patient to be 2. Demonstrate stable vital signs pressure, compare transferred to critical area for stable vital signs and absence of BP readings in both monitoring of ICP, other and absence of increased ICP. arms. therapies. If the stroke is increased ICP. 3. Display no evolving, patient can 3. Display no further 3. Heart rate and deteriorate quickly and require further deterioration or rhythm, assess for repeated assessment and deterioration or recurrence of murmurs. progressive treatment. If the recurrence of deficits. 4. Respirations, noting stroke is “completed,” the deficits. patterns and neurological deficit is GOAL WAS NOT MET rhythm (periods nonprogressive, and treatment of apnea after is geared toward rehabilitation hyperventilation), and preventing recurrence. Cheyne-Stokes 2. Fluctuations in pressure may respiration. occur because of cerebral injury in vasomotor area of 5. Evaluate pupils, the brain. Hypertension or noting size, shape, postural hypotension may equality, light have been a precipitating reactivity. factor. Hypotension may occur because of shock 6. Document changes (circulatory in vision: reports of collapse). Increased ICP may blurred vision, occur because of tissue edema alterations in visual or clot formation. Subclavian field, depth artery blockage may be perception. revealed by difference in 7. Assess higher pressure readings between functions, including arms. speech, if patient is 3. Changes in rate, especially alert. bradycardia, can occur because of the brain damage. 8. Position with head Dysrhythmias and murmurs slightly elevated may reflect cardiac disease, and in neutral which may have precipitated position. CVA (stroke after MI or from 9. Maintain bedrest, valve dysfunction). provide quiet and 4. Irregularities can suggest relaxing location of cerebral environment, insult or increasing ICP and restrict visitors and need for further intervention, activities. Cluster including possible respiratory nursing support. interventions and 5. Pupil size and equality is provide rest periods determined by balance between care between parasympathetic and activities. Limit sympathetic innervation. duration of Response to light reflects procedures. combined function of the optic (II) and oculomotor (III) cranial nerves. 6. Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions. 7. Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration or increased ICP. 8. Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion. 9. Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage. ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION OBJECTIVE: Impaired verbal After 24 hours, the 1. Listen for 1. Feedback helps patient After 24 hours, the errors in realize why caregivers CVD patient communication r/t patient will; conversation are not understanding patient will; and provide or responding Difficulty of to alteration in feedback. appropriately and 1. Indicate an 2. Point to provides opportunity 1. Indicate an speech perception as objects and ask to clarify meaning. understanding understanding patient to 2. Tests for expressive of the of the Restlessness name them. aphasia. Patient may evidenced by communication communication 3. Ask patient to recognize item but not problems. write his name be able to name it. problems. NGT Feed difficulty of 2. Establish and a short 3. Tests for writing 2. Establish method of sentence. If disability (agraphia) method of Unable to comprehending or unable to and deficits in reading communication communication write, have comprehension communicate in which needs in which needs maintaining patient read a (alexia), which are can be can be short sentence. also part of receptive VS taken: communication. expressed. 4. Write a notice and expressive expressed. 3. Use resources at the nurses’ aphasia. 3. Use resources BT: 36 station and 4. Allays anxiety related appropriately. appropriately. patient’s room to inability to BP: 180/120 about speech communicate GOAL WAS NOT MET impairment. and fear that needs PR: 78 Provide a will not be met special call promptly. RR: 18 bell that can be 5. Helpful in decreasing activated by frustration when minimal dependent on others pressure if and unable to necessary. communication 5. Anticipate and desires. provide for 6. Reduces confusion and patient’s allays anxiety at needs. having to process and 6. Talk directly respond to large to patient, amount of information speaking at one time. As slowly and retraining progresses, distinctly. advancing complexity Phrase of communication questions to be stimulates memory answered and further enhances simply by yes word and idea or no. Progress association. in complexity 7. Assesses individual as patient verbal capabilities and responds. sensory, motor, and 7. Respect cognitive functioning patient’s to identify preinjury deficits/therapy needs. capabilities; avoid “speaking down” to patient or making patronizing remarks. 8. Consult and refer patient to speech therapist.