NURSING

CARE
MANAGEMENT
Ineffective Cerebral Tissue
Perfusion
related to
Narrowing and Occlusion
of Cerebral Artery
Subjective Cues:
“mura gyapon siyag gakalipong, mo storya siya na dili
masabatan pero murag ingon niya na lipong daw ” as
verbalized by the watcher

Objective Cues:

• BP = 180/80mmHg
• Drowsiness noted
• Decreased level of consciousness
• Left-Sided Body Weakness noted
• Uneasiness noted
 GOALS AND OBJECTIVES

SHORT TERM:
• Within 2-3 hours of nursing intervention,
• Client will demonstrate adequate tissue perfusion AEB blood
pressure, pulse rate and rhythm within normal parameters for
client; strong peripheral pulses, and ability to tolerate activity
without dyspnea, syncope or chest pain

Long term:
• Within 2-3 days of nursing intervention,
• Client will verbalize knowledge of their treatment regimen,
including appropriate exercise and medications, their actions
and possible side effects
NURSING INTERVENTIONS AND RATIONALE

INDEPENDENT:
• Monitor vitals signs such as Respi Rate, Pulse Rate and Blood
Pressure
• Promote rest periods with body flat on bed and turn to sides every
two hours
• Provide safety such as lowering level of bed, putting pillows on
the side of the patient, or assisting person on bed mobility
• Encourage patient to avoid stressful situation

DEPENDENT:
• Administer Anti-hypertensive drugs such as Captopril

COLLABORATIVE 
• 1. REPORT TO HEALTH CARE TEAM OF ANY ABNORMALITIES
Activity Intolerance
related to
Loss of Muscle
strength
Subjective Cues:
“dili siya makalihok pag siya ra isa” as verbalized by the
watcher......

Objective Cues:
 
• Impaired ability to turn to sides, move from supine to sitting
position and to reposition self in bed noted
• Weakness noted
• Vital signs
• = 170/100
• = 28cpm
• =110bpm
 
Functional level classification
= 2 (requires help from another person)
 GOALS AND OBJECTIVES
Short term
• Achieve improved activity tolerance in terms of
turning to sides, and of changing positions
• Maintain position that allows improved function and
skin integrity as evidenced by absence of
contractures, decubitus ulcers and so forth  

• Long term 
• Demonstrate behaviors/techniques that enable
completion of Activities of Daily Living such as
toileting, eating, grooming, bathing and etc.
NURSING INTERVENTIONS AND RATIONALE

Independent
• Evaluate client’s actual and perceived limitation /degree
of deficit in light usual status.
• Turn dependent client frequently (every 2 hours),
utilizing bed and mattress positioning settings to assist
movements, reposition in good body alignment, using
appropriate support
• Instruct client and caregivers aim for positions which is
most comfortable to client
• Observe skin for reddened areas/shearing. Provide
appropriate pressure relief to reduce friction, maintain
safe skin and wick away moisture
• Instructed SO’S to limit the activities/exertion of the
client
• Assist in learning and demonstrating appropriate
safety measures
• Encourage to have early ambulation
• Encourage to maintain positive attitude; suggest use of
relaxation techniques. Such as visualization/guided
imagery and deep breathing exercise
• Explain to the client the importance od Range of
motion exercises.
• Assist patient in doing Passive Range of Motion.
 
Collaborative
• Include physical therapist in creating movement
program, and Range of Motion Exercises when
indicated with bed rest
Risk for impaired skin
integrity related to
decrease activity to move
 
Risk Factors:
• body weakness(left sided)
• Limited movement
• slightly decreased ROM
GOALS AND OBJECTIVES

Short term:
• Patient and significant (SO’s) identify the risk factors
• Patient and significant others (SO’s) verbalize
understanding of the importance of treatment/
therapy regimen.
• Maintain position that allows improved function and
skin integrity as evidenced by absence of
contractures, decubitus ulcers and so forth
 
Long term:
• •Demonstrate behaviors/techniques to prevent skin
breakdown
NURSING INTERVENTIONS and RATIONALE

Independent:
• Assess skin routinely, noting moisture, color, and
elasticity.
• Observed for reddened/blanched areas of skin
• Instruct SO’S the need/importance of massaging the
bony prominences and the use of proper positioning,
turning, lifting and transferring when moving client
• Instruct and demonstrate change position in bed/chair
on a regular schedule and encourage early
ambulation, active and assistive range-of-motion
• Instructed the importance of adequate clothing/covers;
protect from drafts
• Keep bedclothes dry and wrinkle free, use
nonirritating linens and provide protection by
use of pillows
• Instructed SO’S to change diapers frequently;
cleanse perineal skin daily and after
incontinence episode
• Emphasize importance of adequate
nutritional/fluid intake
• Keeping the nails short

Collaborative:
• Refer to dietitian as appropriate as the finances
availability
EVALUATION

Goals met
• At the end of 8 hours nursing management patient
was able to:
• patient and SO’S identified the risk factors that could
contribute to skin breakdown
• SO’S verbalized understanding regarding the need of
treatment to prevent from any additional
complication
•Patient maintained position that allow her improved
her comfort and skin integrity
•Demonstrate behaviors in preventing skin breakdown
Risk of Injury related to
Decreased ability to move
secondary to
Left-Sided Body Weakness
Risk factors:

• decreased LOC
• left sided weakness noted
• altered thought processes
• Extremes of Age : 71 years old
GOALS AND OBJECTIVES

• Understanding of risk factors that

contribute to possibility of injury,
• Demonstrate behaviors, lifestyle
changes to reduce and protect from
injury as well as to be free from
injury.
NURSING INTERVENTIONS AND RATIONALE

INDEPENDENT
• Assess the person for factors known to increase
injury risk such as history of falls, mental status
changes and sensory deficits.
• Assess patient’s environment for factors known to
increase fall risk such as unfamiliar setting and
inadequate lighting.
• Perform thorough assessments regarding safety
issues when planning for client care
• Place items used by the patient within easy reach
and maintain bed/chair in lowest position with
wheels locked.
• Keep the side rails of the raised.
• Frequent skin inspections.
• Encourage the patient to participate in a
program of regular exercise

COLLABORATIVE
 Refer the person for diagnostic
musculoskeletal evaluation.
• Refer the family to community resources
for assistance in making home safety
modifications
 EVALUATION

GOALS MET.
 
At the end of 8 hours of nursing intervention,
Patient was able to:
• verbalized understanding on risk factors that may
contribute to possibility of injury,
• demonstrated behaviors to be free from injury and
that safety is ensured.
Altered Nutrition:
Less than body
requirements
related to
Altered Ability to
Swallow
SUBJECTIVE CUES:
• “Dili kayo siya maka tulon ug maayo mauna gamay ra
iyang gaka kaon” as verbalized by the watcher

OBJECTIVE CUES:
• Body weight of 56 kg.
• Weakness of muscles (i.e. tongue muscles) required for
swallowing or mastication
• Dry and pale mucous membranes
• Brittle Hair
• Lab results:
• Decreased albumin:
• Electrolyt///e imbalance:
• Na+:
GOALS & OBJECTIVES
Short Term
• Verbalize understanding of causative factors when
known & necessary interventions
• Demonstrate behaviors, to regain appropriate weight,
by consuming at least ½ to ¾ of food serving

Long Term 
• Demonstrate progressive weight gain of at least 2 lbs.
from previous weight
 NURSING INTERVENTIONS
AND RATIONALE
INDEPENDENT:
•Determine the patient’s ability to chew, swallow
& taste food.
•Weigh as indicated. Evaluate weight in terms of
premorbid weight. Compare serial weights &
anthropometric measurements.
•Encourage client to choose foods or have family
members bring foods that seem appealing .
•Advise patient to limit consumption of bulk/fiber
foods.
•Promote timely fluid intake.
•Encourage the use of lozenges and so forth.
DEPENDENT:
• Administer pharmaceutical agents like
appetite stimulants as indicated.
• Administer vitamin/mineral (iron)
supplements including chewable
multivitamin medications as indicated.

COLLABORATIVE:
• Consult dietitian or nutritional team, as
indicated.
EVALUATION
Goals Met.

After 8 hours of duty, my patient was able to:

• Verbalize understanding of causative factors
when known & necessary interventions
• Demonstrate behaviors, to regain appropriate
weight, by consuming at least ½ to ¾ of food
serving.

After 2 weeks of duty, my patient was able to:

• Gain 2 lbs. after admission.
 Hyperthermia
related to Compromised
Cerebellar
Thermoregulatory
Function
secondary to
Middle Cerebral Artery
Infarction
Subjective:
• “Ma’am, nikalit lang siya’g init karong hapon”
as verbalized by the watcher.

Objective: 
• Temperature: 38.3˚C
• Skin Warm to touch
• Dry Skin Noted
• Warm Breath noted
GOALS & OBJECTIVES
After 20 mins of nursing interventions:

• Patient’s temperature from

38.3˚C→37.5˚C
• The patient will be free from any
complications due to Hyperthermia
NURSING INTERVENTIONS AND
RATIONALE
INDEPENDENT:
• Explain to the client the importance of Tepid
sponge Bath.
• Perform Tepid sponge Bath
• Do mouth Care Carefully
DEPENDENT:
• Administer PARACETAMOL 500mg.
• R: to help lower patient’s temperature.
EVALUATION
Goals met as evidenced by :
• Temperature 37.5˚C
• (―) dry skin
• (―) Warm breath
Deficient Knowledge
related to
Unfamiliarity with
regards to condition
and treatment
regimen
Subjective Cue:
• “Unsa diay ni ako sakit day? Unsay rason?
Unsa amo buhaton?” as verbalized by the
patient
 
Objective Cues:
• Educational Status- undergraduate of
Elementary; only until fifth grade
GOALS AND OBJECTIVES
Short Term:

After 2 hours of Nursing Intervention the patient

will be able to:
• Participate in learning process
• Identify interferences to learning and specific
action to deal with them.
• Verbalized understanding of condition or
disease process and treatment.
• Initiate necessary lifestyle changes and
participate in treatment regimen.
NURSING INTERVENTIONS AND
RATIONALE
INDEPENDENT:
• Ascertain level of knowledge, including
ancipatory needs
• Discuss client’s perception o need. Relate
information to client’s personal desires or
needs and values or beliefs.
• Identify information that needs to be
remembered
• Determine client’s method of accessing
information to facilitate learning.
• Provide mutual goal setting and learning
contracts.
• Begin with information the client already
knows and move to what the client does not
know, progressing from simple to complex.
Limit sense of being overwhelmed.
• Deal with the client’s anxiety. Present
information out of sequence, If necessary,
dealing first with material that is most
anxiety-producing when anxiety is
interfering with the client’s learning process.
• Be aware of informal teaching and role
modeling that takes place on an ongoing
basis.
• Assist client to use information in all
applicable areas.
EVALUATION

Goal’s Met.

After 2 hours of nursing intervention, the

patient was able to participate the learning
process and able to understand the condition
or disease process and treatment.