ASSESSMENT NURSING

DIAGNOSIS
INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

hindi nya
magalaw yang
kaliwang kamay
at paa nya ng
kusa as
verbalized by
his wife

Objective:
> Slurring of
speech
> Weakness on
left arm and leg
> difficulty in
swallowing



Ineffective
cerebral tissue
perfusion
related to
interruption of
blood flow as
manifested by
changes in
motor
responses



Increase LDL
levels


Accelerated
atherosclerosis



Decreased
Tissue
perfusion in
brain


interruption of
blood flow in
brain


Ineffective
cerebral tissue
Perfusion







After 4 days of
nursing
intervention the
client will have
an effective
cerebral tissue
perfusion as
manifested by:

> display no
furher
deterioration of
deficits

>vital signs
within clients
normal range



>Establish
rapport

>Monitor vital
signs

> Monitored
intake and output

> Position with
head slightly
elevated and in
neutral position



> Clustered and
organized
activities of the
client

> Encourage
rest.







>To gain trust and
cooperation

>To obtain baseline
data

> to prevent volume
overload and deficit

> Reduces arterial
pressure by
promoting venous
drainage and may
improve cerebral
circulation/perfusion.

> to reduce
uneccesarry
movement and
stimulation

> Rest prevents
tissue oxygen
demand and
enhances tissue
oxygen perfusion.




GOAL MET.

After 4 days of
effective
nursing
intervention the
client is able to
Maintain usual
level of
consciousness,
motor function
and vital signs
within normal
range


II. NURSING CARE PLAN
Nursing Priority No. 1: Ineffective cerebral tissue perfusion related to interruption of blood flow as manifested by
changes in motor responses



Cerebral
Hypoxia



Cerebral
ischemia


loss of cerebral
connections for
afferent sensory
and efferent
motor nerves


changes in
motor
responses


inability to
purposely move
involved body
parts



> Instructed
client and family
members in ways
to minimize risk
factors for altered
tissue perfusion

>administer
medications as
ordered.
> Increases the
probability that
healthy adaptation
will continue