ASSESSMENT NURSING SCIENTIFIC RATIONALE PLANNING INTERVENTION RATIONALE EXPECTED

DIAGNOSIS OUTCOME

OBJECTIVE: Ineffective Ineffective tissue perfusion Short-term: 1. Maintain 1. To maintain Short-term:

 Determine Tissue Perfusion refers to a lack of oxygenated blood cerebral perfusion,
baseline related to blood flow to specific areas of Within 4-6 hrs of pressure. blood pressure is Within 4-6 hrs of NI,
presentatio Interruption of the body. Proper perfusion is Nursing intervention, kept elevated. For the patient will display
n. blood flow to the critical for organ and body the patient will 2. Educate on ischemic strokes, improved cerebral
brain as system function, as damaged display improvement risk factors of the blood pressure perfusion as evidenced
 Perform evidenced by organs and tissues can lead to in cerebral perfusion strokes. may be allowed as by vital signs within
neurologic Altered mental death. as evidenced by vital high as 220 ordered parameters.
al status signs within ordered 3. Instruct on systolic (unless
assessment parameters. symptoms of a receiving Long-term:
s. stroke using thrombolytic
Long-term: FAST. therapy) and no After 3-5 days of NI,
 Obtain a lower than 140 the patient will display
CT scan or After 4-5 days of NI, systolic for a improvement in stroke
MRI of the the patient will hemorrhagic deficits such as slurred
brain. independently stroke. Specific speech, weakness, and
perform Activities of parameters will be swallowing ability by
Daily Living. ordered by the discharge.
provider.

2. If the patient only

experiences a TIA
or does not suffer
long-term deficits
from a stroke,
prevention of a
future stroke
 should be
communicated.
Risk factors
include
hypertension,
heart disease,
diabetes, smoking,
and stress. These
are modifiable risk
factors that the
patient can work
towards changing
through diet,
exercise, and
lifestyle behaviors.

3. “Time is tissue” in
the instance of a
stroke. The sooner
symptoms are
recognized, the
quicker the
treatment, and less
sustained damage
to brain tissue.
Patients and
family members
should be
instructed on the
acronym F.A.S.T
which stands for
 Facial drooping,
Arm weakness,
Speech difficulty,
and Time.
OBJECTIVE: Risk For Injury Depending on the area of the Short-term: 1. Use bed and 1. When patients Short term:
 Determine related to Poor brain affected by the stroke, the chair alarms. suffer a right-brain
deficits motor patient may have spatial- Within 2-4 hours of stroke specifically, Within 2-4 hours of
related to coordination perceptual issues and impaired nursing interventions 2. If a patient they may be more nursing interventions
the area of judgment. Along with deficits and teaching, the has a new impulsive and and teaching, the
brain in swallowing, motor patient will remain onset of deny or minimize patient will remain free
injury. coordination, and generalized free of injuries. confusion their deficits. This of injuries.
weakness, safety is a priority. (delirium), puts them at high
 Assess Long term: render reality risk for injury and Long term:
sensory orientation falls. Keeping a
awareness. Within 8 hours of when bed alarm on at all Within 8 hours of
nursing intervention interacting times and a chair nursing intervention
 Note and treatment, the with them. alarm if they are and treatment, the
neglect or patient will Have family sitting up will patient will determine
visual determine the factors or significant increase safety. the factors that
disturbance that increases their other bring in increases their risk for
s. risk for injury and familiar 2. Reality orientation injury and will
will demonstrate objects, can help limit or demonstrate behaviors
behaviors to avoid clocks, and decrease the to avoid injury.
injury. watches from confusion that
home to increases the risk
maintain of injury when the
orientation. patient becomes
agitated.

3. Assist with 3. Patients with

eating. dysphagia will
 require special
meals and
thickened liquids.
Ensure they are
chewing and
swallowing
adequately and are
not displaying
signs of possible
aspiration such as
pocketing food,
drooling, or
coughing.

OBJECTIVES: Impaired Verbal Cerebrovascular accidents often Short term: 1. Speak in short, 1. Always speak Short term:
Communication result in deficits in direct clearly, facing the
 Note type related to communication. Patients may Within 3-4 hours of sentences. patient so they can Within 3-4 hours of
of aphasia Dysarthria as struggle with comprehending or nursing intervention see your lips and nursing intervention
evidenced by expressing speech as well as a the patient will 2. Utilize expressions. Use the patient will
 Observe slurred speech. physical inability to produce improve his alternative direct sentences as improve his
how the meaningful speech. communication. communicatio they may not be communication.
patient n methods. able to
communic Long term: comprehend Long term:
ates. 3. Encourage abstract thoughts.
Within 3-4 hours of family Short “yes” or Within 3-4 hours of
 Evaluate nursing intervention participation. “no” questions nursing intervention
mental the patient will be may be easiest for the patient will be able
status. able to express his the patient to to express his thoughts
thoughts and needs. comprehend. and needs.

2. Use writing,
 drawing, and
flashcards if these
work for the
patient. The nurse
and patient may be
able to work out a
system to
communicate
needs such as a
thumbs up or
down, eye
blinking, or
smiling if they are
nonverbal.

3. Family
involvement is
crucial as both the
patient and family
learn to maneuver
communication
changes. Family
members should
also participate in
therapy sessions
and learn specific
techniques that
support clear
communication.
Ccm, M. W. B. R. (2023, February 24). Stroke (CVA) Nursing Diagnosis & Care Plan | NurseTogether. NurseTogether. https://www.nursetogether.com/stroke-
cerebrovascular-accident-nursing-diagnosis-care-plan/

Ccm, M. W. B. R. (2023, February 24). Stroke (CVA) Nursing Diagnosis & Care Plan | NurseTogether. NurseTogether. https://www.nursetogether.com/stroke-
cerebrovascular-accident-nursing-diagnosis-care-plan/