BUYA, Genesis Ivy T BSN III-A3 MEDICAL SURGICAL (ALA) June 21, 2021

NURSING CARE PLAN

Nursing Diagnoses:

Nursing Diagnosis Rationale

1. Ineffective Cerebral Tissue Perfusion related to interruption of blood
flow
Blood flow to the brain is called cerebral perfusion pressure. If the blood
pressure is low and/or the intracranial pressure is high, the blood flow to the
brain may be limited. This causes decreased cerebral perfusion pressure.
Adequate cerebral perfusion pressure (CPP) is essential to prevent cerebral
ischemia or toxic pooling of inflammatory mediators. When CPP falls below
the lower limit of autoregulation, the brain is at risk of inadequate blood flow.
In the patient’s cases, this can now further damage the brain which in result
further damage the patient’s level of consciousness, cognition and motor/
sensory function impairing speech, visual capacity, muscle strength and other
body functions. Being hypertensive, capillary rarefaction induces an increase
in blood pressure, a relative decrease in tissue perfusion and an increased
cardiovascular risk.

Reference/s:
 Ruthirago, D. & DeToledo, J.C. (2017) Autoregulation of Cerebral
Blood Flow. Retrieved from
https://www.sciencedirect.com/topics/agricultural-and-biological-
sciences/cerebral-perfusion-pressure
 University of Iowa: Hospitals and Clinics (2016) What is cerebral
perfusion pressure? Retrieved from https://uihc.org/health-
topics/what-cerebral-perfusion-pressure
 Mourad, J. & Laville, M. (2006) Is hypertension a tissue perfusion
disorder? Implications for renal and myocardial perfusion. Retrieved
from https://pubmed.ncbi.nlm.nih.gov/16936530/
2. Disturbed Sensory Perception: Visual related to altered sensory Visual perception is the brain's ability to interpret what is seen. Visual
reception perception is necessary for reading, writing, and movement. Without it, the
patient may find daily tasks extremely stressful. Individuals with vision
impairment are also more likely to experience restrictions in their
independence, mobility, and educational achievement, as well as an
increased risk of falls, fractures, injuries, poor mental health, cognitive
deficits, and social isolation.

3. Impaired Verbal Communication related to neuromuscular
impairment: loss of oral muscle control
Reference/s:
 National Academies of Sciences, Engineering, and Medicine; Health
and Medicine Division; Board on Population Health and Public Health
Practice; Committee on Public Health Approaches to Reduce Vision
Impairment and Promote Eye Health; Welp A, Woodbury RB, McCoy
MA, et al., editors. Making Eye Health a Population Health
Imperative: Vision for Tomorrow. Washington (DC): National
Academies Press (US); 2016 Sep 15. 3, The Impact of Vision Loss.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK402367/
 LUMIERE (2020) Why Is Visual Perception so Important? Retrieved
from https://www.lumierechild.com/lumiere-childrens-therapy/why-
is-visual-perception-so-important
The inability to communicate enhances a patient's sense of isolation and may
promote a sense of helplessness. Furthermore, when patient is unable to
communicate, some of his needs may become unmet as misunderstandings
and confusions may result when communicating to caregiver or nurse about
his needs.

Reference:
 Wayne, G. (2017) Impaired Verbal Communication Nursing Care Plan.
Retrieved from https://nurseslabs.com/impaired-verbal-
communication/

Care Plan:
Priority Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow

Expected Outcomes Nursing Interventions Rationale

LTO: After 4 days of nursing Diagnostic:

interventions, patient will demonstrate
increased perfusion
STO: After 8 hours of nursing
interventions the patient will be able
to:
 Demonstrate stable vital signs
as evidenced by blood pressure
maintained at 140/90 mmHg
and respirations less than or
 Assess and monitor neurological
status frequently and compare with
baseline
 Monitor Vital Signs
-Changes in blood pressure compare
BP readings in both arms.
-Heart rate and rhythm assess for
 Assesses trends in level of consciousness (LOC) and
potential for increased ICP and is useful in determining
location, extent, and progression of damage.
-High blood pressure damages arteries and makes them
more likely to tear or burst. Hypertension also can cause
clots.
-Changes in rate, especially bradycardia, can occur because
of the brain damage. Dysrhythmias and murmurs may
 equal to 20.
 Maintain usual level of
consciousness, cognition and
motor/ sensory function as
evidenced by GCS score not
lower than 10.
 Display no further
deterioration or recurrence of
deficits.
Therapeutic:
murmurs
-Respirations, noting patterns and
rhythm
 Evaluate pupils, noting size, shape,
equality, light reactivity.
 Document changes in vision: reports
of blurred vision, alterations in visual
field, depth perception.
 Assess higher functions, including
speech, if patient is alert.
 Monitor input and output
 Position with head slightly elevated
and in neutral position.
 Maintain bedrest, provide quiet and
relaxing environment, and restrict
visitors and activities. Cluster nursing
interventions and provide rest
periods between care activities. Limit
duration of procedures.
 Prevent straining at stool, holding
breath.
 Administer supplemental oxygen as
indicated.
reflect cardiac disease, which may have precipitated CVA
-Irregularities can suggest location of cerebral insult or
increasing ICP and need for further intervention, including
possible respiratory support.
 Pupil reactions are regulated by the oculomotor (III) cranial
nerve and are useful in determining whether the brain stem
is intact. Pupil size and equality is determined by balance
between parasympathetic and sympathetic innervation.
Response to light reflects combined function of the optic (II)
and oculomotor (III) cranial nerves.
 Specific visual alterations reflect area of brain involved,
indicate safety concerns, and influence choice of
interventions.
 Changes in cognition and speech content are an indicator of
location and degree of cerebral involvement and may
indicate deterioration or increased ICP.
 Maintenance of an adequate fluid balance is vital to health.
Inadequate fluid intake or excessive fluid loss can lead to
dehydration, which in turn can affect cardiac and renal
function and electrolyte management. Inadequate urine
production can lead to volume overload, renal failure and
electrolyte toxicity.
 Reduces arterial pressure by promoting venous drainage
and may improve cerebral perfusion.
 Continuous stimulation or activity can increase intracranial
pressure (ICP). Absolute rest and quiet may be needed to
prevent re-bleeding in the case of hemorrhage.
 Valsalva maneuver increases ICP and potentiates risk of re-
bleeding.
 Reduces hypoxemia. Hypoxemia can cause cerebral
vasodilation and increase pressure or edema formation.
  Administer medications as ordered:
- Alteplase (Activase), t-PA
- Antihypertensives (Amlodipine,
Clonidine, Losartan)
- Antiarrhythmic (Amiodarone)
- Diuretics (Mannitol)
- Stool softeners (Dulcolax)
 Assist patient in doing ADLs and in
exercise.
Educative:
 Discuss impact of unmodifiable risk
factors such as family, history, age,
and race.
Thrombolytic agents are useful in dissolving clot when
started within 3 hr of initial symptoms. Thirty percent
are likely to recover with little or no disability.
Treatment is based on trying to limit the size of the
infarct, and use requires close monitoring for signs of
intracranial hemorrhage.
Chronic hypertension requires cautious treatment
because aggressive management increases the risk of
extension of tissue damage.
Antiarrhythmic medications prevent and treat
abnormal heartbeats. If arrhythmia is left untreated,
the heart may not be able to pump enough blood to
the body. This can further damage, the brain, and
damage the heart or other organs
Mannitol can activate the process of apoptotic cell
death and has the potential to activate the
inflammatory mediators that aggravate the neuronal
injury due to ischemia. In acute stroke, mannitol
preferentially shrinks the nonaffected parts of the
brain.
Prevents straining during bowel movement and
corresponding increase of ICP.
 Exercise in any form is important for rehabilitation. The
coordination of movements brings about positive emotions
thanks to endorphins. Even swaying side-to-side or rocking
mobile parts of the body helps increase blood flow and is
likely to make patients feel better.
 Understanding effects and interrelationship of all risk
factors may encourage client to address what can be
changed to improve general well- being.
 Passive exercise helps with recovery because it involves
 Demonstrate passive exercises using your non-affected side to move your muscles; and
any type of movement sends signals to the brain

 Physical inactivity is a risk factor for stroke, so exercising

 Explain importance of exercise can help prevent a recurrent stroke.

 An unhealthy diet can increase your chances of having a

 Emphasize compliance to diet: low stroke because it may lead to an increase in your blood
salt and low fat diet pressure and cholesterol levels